Adults exam 1

Intra-operative precautions Psychological support

(before induction & when a patient is conscious) 1. Provides emotional support to PT 2. Stands near or touches patient during procedures & induction

Preoperative instructions to prevent postoperative complications

***One goal of preop nursing care is too educate the patient how to promote optimal lung expansion & resulting blood oxygenation after anesthesia. The patient assumes a sitting position to enhance lung expansion***

Pre-Operative Instructions

***The Goal of the preoperative period is for the patient to be as healthy as possible, every attempt is made to assess for & address risk factors that may contribute to postop complications & delay recovery***

Hypotonic Fluids Memory**HYPO- HIPPO (tonic) (swell)

- A solution where the fluid goes into cell, the cell swells -solutions containing a lower concentration of salt than ICF -diluted fluids- less salts- more water

Hypertonic Fluids Memory** HYPER-Hyper person (super skinny)

-A solution where the fluid goes out of the cell, cell shrinks -Solutions containing a higher concentration of salt then ICF -thick fluids-more salt-less water

Hypervolemia (FVE) S/S:

-Acute weight gain -Peripheral edema -distended jugular veins -crackles, -elevated CVP -SOB -↑ BP -↑ pulse -bounding -↑ cough -↑ RR -↑ Urine Output

Hypovolemia (FVD) Signs and Symptoms:

-Acute weight loss - decrease skin turgor -oliguria -concentrated urine -cap refill time prolonged -low CVP -decrease BP -flat neck veins -dizziness -weakness -thirst -confusion -increase pulse -muscle cramps -sunken eyes -nausea -increased temp -cool clammy pale skin

Hypovolemia (FVD) Medical Management:

-Administration or Oral fluids & Parenteral fluids -If the deficit is not severe, the oral route is preferred (if the patient can drink), if fluid losses are acute or severe, the IV route is used)

Intra-operative precautions Potential Complications:

-Anesthesia awareness -Nausea and vomiting -Anaphylaxis -hypoxia and other respiratory complications -Hypothermia -Malignant hyperthermia

Hyponatremia S/S:

-Anorexia -N/V -Headache -Dizziness -Confusion -Muscle cramps -Weakness -Muscle twitching -Seizures -Dry skin -↑pulse -↓ BP -Weight Gain -Edema -Coma -RR arrest

Immediate PreOp Nursing Interventions

-Assess for latex or any other allergies -Patient changes into gown, hair covered, mouth inspected, jewelry removed, valuables stored in a secure place -Administering pre-anesthetic medication -Maintaining preoperative record -Transporting the patient to a pre surgical area -Attending to family needs

Hyperkalemia (High K+) Causes:

-Can occur in patients with normal renal function, increased risk in older adults, cardiac arrest is frequently associated -Seen in patients with kidney disease/injury, addison's disease, injuries and burns, NSAIDS & ace inhibitors

Patient Education

-Deep breathing, coughing, incentive spirometry -Mobility, active body Movement -Pain Management -Cognitive coping strategies -Instruction for patients undergoing ambulatory surgery

Diaphragmatic Breathing:

-Diaphragmatic Breathing refers to a flattening of the dome of the diaphragm during inspiration, during expiration the abdominal muscles contract. 1) Practice in the same position you would assume in bed after surgery; semi-fowler position, propped in bed with the back and shoulders well supported with pillows 2) Feel the movement with your hands resting lightly on the front of the lower ribs and fingertips against the lower chest. 3) Breathe out gently and fully as the ribs sink down and inward toward the midline 4) Take a deep breath through your nose and mouth 5) Hold this breath for a count of 5 6) Exhale and let out all the air through your nose and mouth 7) Repeat his exercise 15 times with a short rest after each group of 5 8) Practice this twice a day preoperatively

Hypokalemia (LOW K+) Clinical Manifestations:

-ECG changes -Dysrhythmias -Dilute urine -Excessive thirst -Diarrhea -Vomiting -Starvation -Paraesthesia -Muscle weakness

Pre-Operative Assessment #2

-Endocrine function -Immune function - Previous medication use -Psychosocial Factors -Spiritual & Cultural beliefs

Hypervolemia (FVE) Causes:

-FVE may be related to simple fluid overload or diminished function of the homeostatic mechanisms responsible for regulating fluid balance -Heart Failure, Kidney injury, cirrhosis of the liver -Consumption of excess amounts of table salt or other sodium salts -Excessive administration of sodium-containing fluids

Hypokalemia (LOW K+) S/S:

-Fatigue -Anorexia -Nausea -Vomiting -Muscle weakness -Polyuria -↓ bowel motility -ECG -**POTASSIUM & HEART** -↓ BP,

Hypernatremia (High Na+) Patho:

-Fluid deprivation in patients that do not respond to thirst, excess sodium administration, diabetes insipidus, heat stroke, hypertonic IV solutions. -Water is moving from the tissues into the bloodstream, causing cells to shrink

Pre-Operative Assessment #1

-Health History & Physical Exam -Medications & Allergies -Nutritional & Fluid status -Dentition -Drug or alcohol use -Respiratory & Cardiovascular status -Hepatic & Renal function

Hypernatremia (High Na+)

-High Sodium -Sodium=NA+ (Serum Sodium More than 145 mEq/L)

What Potentiates DIG toxicity

-Hypokalemia -Most HF patients are on Lassie, watch potassium (K+)

Hypervolemia (FVE) Nursing Management:

-I&O -Daily Weights -Assess Lung sounds -Edema -Monitor response to medications -Promote adherence to fluid restrictions, patient teaching related to sodium and fluid restrictions -Monitor and avoid sources of excessive sodium -Promote rest

Hypovolemia (FVD) Nursing Management:

-I&O every 8 hours, sometimes hourly -Daily Weight -Vital signs monitored -Assess mental status, urine output (color, odor), skin and tongue turgor, mucosa -Measures to minimize fluid loss

In the Pre-Op area

-Identify Patient -Assesses patient's physical & emotional status, baseline pain & nutritional status -Reviews medical record Verifies surgical site and that it has been marked per institutional policy -Establishes IV line -Administers medications if prescribed -Takes measures to ensure patient comfort -Provides Psychological support -Communicated patient & family needs to other members of healthcare team

Hypernatremia (High Na+) Medical Management:

-Infusion of a hypotonic solution -Assess for OTC sources of sodium

When is informed consent necessary?

-Invasive procedures, such as surgical incision, biopsy, cystoscopy, or paracentesis -Procedures requiring sedation or anesthesia -A non-surgical procedure, such as an arteriography carries more than a slight risk to the patient -Procedures involving radiation -Blood product administration

Hyperkalemia (High K+) Nursing Management:

-Limit potassium & diet teaching -Be aware of patients at risk for potassium excess (kidney disease) -Monitor I&O -Monitor S/S of muscle weakness and arrhythmias

Hypokalemia (LOW K+) Causes:

-Medications (Loop diuretics, Thiazides, corticosteroids) -GI loss -Vomiting & gastric suction -potassium is lost through the kidneys in response to metabolic alkalosis -Alteration in acid base balance -Not able to eat normal diet

Hyperkalemia (High K+) Medical Management:

-Monitor ECg, HR (apical), BP, Assess labs & Monitor I&O -Administration of Cations -EMRG care: IV calcium Gluconate, IV sodium bicarbonate, IV regular insulin, Hypertonic dextrose, Beta 2-agonists, dialysis -Administer IV slow!!!

Hyponatremia Nursing Management:

-Monitor I&O (identify excess water input or lack of water output) -Daily Weights -Any CNS changes -confusion? **SODIUM & NUERO*** -History -Are they a performance athlete? -Nursing Alert: **The nurse observes for a weak, rapid pulse and orthostatic hypotension when the patient moves from lying to sitting**

Hypernatremia (High Na+) Nursing Management:

-Monitor for CNS changes **SODIUM & NUERO*** -Assessment for abnormal loss of water & low water intake (loss & gains) -Medical history -Notes pt thirst, or elevates body temp -Nursing Alert: **The nurse observes for a weak, rapid pulse and orthostatic hypotension when the patient moves from lying to sitting**

Hyperkalemia (High K+) S/S:

-Muscle weakness -Tachycardia→ bradycardia -Arrhythmias -Cramps -Anxiety -ECG changes

Hypernatremia (High Na+) Causes:

-Occurs in patients with normal fluid volume, FVD & FVE mostly in patients who are very old, very young, or cognitively impaired. -Insensible water losses through lungs or skin (watery diarrhea, hyperventilation, heat stroke), Diabetes insidious (dry inside)

Hypokalemia (LOW K+) Medical Management:

-Oral potassium supplements or IV -A diet sufficient in potassium (dietary intake on average is 50-100 mEq a day) -Foods high in potassium (K+) = Fruits, veggies, whole grains, milk, meat , coffee, tea, eggs, nuts, chicken, salmon, avocado, dried fruits, bananas, yogurt, squash

Post- Op Information (Anesthesia provider- to nurse report)

-Patient name, Gender, Age -Allergies -Surgical Procedure -Position during procedure -Length of time in OR -Anesthetic agents & reversal agents used -Estimated blood/fluid loss -Fluid/Blood loss replacement -Last set of vital signs & any problems during procedure (N/V) -Any complications encountered (anesthetic or surgical) -Medical Comorbidities (Diabetes, Hypertension) -List of Allergies & medications taken at home (including pain meds, antihypertensives, anticoagulants) -Considerations for immediate postoperative period (pain management, reversals, ventilator settings) -Language Barrier -Location of patients family **the Anesthesia provider should not leave the patient until the nurse is satisfied with the patients airway & immediate condition**

Special Considerations during the PreOp Period

-Patients with obesity -Patients with disabilities -Patients undergoing ambulatory surgery -Patients undergoing emergency surgery

Hyponatremia Clinical Manifestations:

-Poor skin turgor -Dry mucosa -Headache -↓ saliva -↓ BP -Nausea -Abdominal cramping -Neurological changes

Patient Positioning

-Positioning depends on the surgical procedure as well as the patient's physical condition -The patient should be as comfortable as possible -Operative field must be adequately exposed -Vascular supply should NOT be obstructed -Respiration should NOT be impeded by pressure of arms on the chest or by a gown that constricts the neck or chest -Nerves must be protected from undue pressure -Safety precautions for those that are obese, thin, or older

Hypokalemia (LOW K+) Nursing Management:

-Potassium Replacement -(NPO?- Ng tube? Or increase diet, Watch potassium levels- don't let it get too low- be proactive) -Monitor patients receiving digitalis (digoxin) for toxicity -Monitor S/S early -Prevention!!!! -Administer IV potassium only after adequate urine output had been established -Cardiac & Bowel Assessment -Monitor ECG & ABGs

General PreOp Interventions

-Providing psychosocial interventions (reducing anxiety, decreasing fear, respecting cultural, spiritual & religious beliefs) -Maintaining patient safety -Managing nutrition, fluids -Preparing Bowel -Preparing Skin -Have the patient Void before administering a premedication to prevent falls & injuries

Hyponatremia Labs:

-Sodium below 135mEq/L -Range 135-145mEq/L -Decreased urine sodium

Hypernatremia (High Na+) Labs:

-Sodium greater than 145 mEq/L -Decreased urine sodium -↓ CVP

Informed Consent

-The patient's autonomous decision about whether to undergo a surgical procedure, based on the nature of the condition, the treatment options & the risks/benefits involved -This is a legal mandate -Should be in writing before non emergent surgery -Consent is valid only when signed before administering psychoactive premedication -The nurse clarifies the information provided, verifies the presence of the patient or designee's signature, and may be asked to sign as a witness -The surgeon must explain the procedure, benefits, risks, complications, etc, if the patient requests more information or an explanation about the surgery you call the physician, the nurse doesn't answer these questions -Any signed form required for surgery is placed in a prominent place on the patient's medical record and accompanies the patient in the OR

Hypernatremia (High Na+) Clinical Manifestations:

-Thirst -Elevated Temp -Increased plasma osmolarity caused by an increase in plasma sodium concentration (water moves out of cell, into the ECF-cellular dehydration)

Hypernatremia (High Na+) S/S:

-Thirst -Increased body temp -Pulmonary edema -N/V -Increased pulse -Increased BP

Hyponatremia Medical Management:

-Treat underlying condition (cause) -Sodium Replacement -Water restriction

Voluntary Consent

-Valid concept must be freely given without coercion. -A patient must be at least 18 yrs old (unless emancipated minor), a physician must obtain consent and the nurse or a professional staff member must witness the patient's signature

Lower osmolarity

-less concentrated -replace fluid inside cell- cellular dehydration

Higher Osmolarity

-more concentrated -pulling fluids out of the cell from (ICF) to ECF- where there is high salt- water gets pulled their to maintain homeostasis

Hypovolemia (FVD) Labs:

-↑ Hemoglobin & Hematocrit -↑ serum and urine osmolarity & specific gravity -↑ BUN & Creatinine (normal ratio is 10:1- a volume depleted pt will have elevated BUN bc the urea becomes concentrated) -↓ urine sodium

Hypervolemia (FVE) Labs:

-↓ Hemoglobin & Hematocrit -↓ Serum & Urine osmolarity -↓ Urine sodium & specific gravity

Coughing

1) Lean forward slightly from the sitting position in bed, interlace your fingers together, and place your hands across the incision site to act as a splint for support when coughing 2) Breathe with the diaphragm 3) With your mouth slightly open, breathe in fully 4) Hack out sharply for three short breaths 5) Ten keeping your mouth open take in a quick deep breath and immediately give a strong cough once or twice

Leg Exercises

1) Lie in a semi-Fowler position and perform the following simple exercises to improve circulation 2) Bend your knee and raise your foot-hold it for a few seconds, then extend the leg and lower it to the bed 3) Do this five times with one leg and then repeat with the other leg 4) Trace circles with the feet by bending them down, in toward each other, up, and then out 5) Repeat these movements five times

Getting out of Bed

1) Turn on your side 2) Push yourself up with one hand as you swing your legs out of bed

Turning to the side

1) Turn on your side with the uppermost leg flexed most and supported on a pillow 2) Grasps the slide rail as an aid to maneuver to the side 3) Practice diaphragmatic breathing and coughing while on your side

Intra-operative precautions Physiologic Monitoring:

1. Communicates amount of fluid instillation & blood loss 2. Distinguishes normal from abnormal cardiovascular data 3. Reports change in patient vital signs 4. Institutes measure to promote normothermia 5. Being alert to changes in cardiac arrhythmias, S/S of nausea and Vom, anaphylaxis, hypoxia, and hypothermia 6. Precautions to decrease SSIs

Intra-operative precautions Maintenance of safety:

1. Maintains aseptic, controlled environment 2. Effectively manages human resources, equipment, and supplies for individualized patient care 3. Transfers pt to operating room bed or table 4. Positions patient based on functional alignment & exposure of surgical site 5. Applies grounding device to patient 6. Ensures that the sponge, needle & instrument counts are correct 7. Completes intraoperative documentation

Hypovolemia (FVD) Causes:

Abnormal Fluid Losses: -such as vomiting, diarrhea, sweating, GI suctioning Decreased Intake: -nausea, lack of access to fluids, anorexia Third-Space fluid Shifts: -due to burns, ascites Other causes: -diabetes insipidus, adrenal insufficiency, hemorrhage

Urinary Post-Op complicaitons

Acute urine retention, urinary tract infection

Hyponatremia Causes:

Acute: Result of fluid overload of a surgical patient (dilute sodium) Chronic: longer duration, more seen outside hospital setting Exercise Associated: More common in women of small stature, extreme temperatures, excessive fluid intake, prolonged exercise

Hypervolemia (FVE) Patho:

An expansion of the ECF caused by abnormal retention of water & sodium in approximately the same proportions in which they normally exist in the ECF that is usually secondary to an increase in total body sodium content

Respiratory Post-Op complicaitons

Atelectasis, pneumonia, pulmonary embolism, aspiration

Intraoperative Phase

Begins when the patient is transferred onto the OR bed and ends with the admission to the PACU

Postoperative Phase:

Begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home

Skin/ Wound Post-Op complicaitons

Breakdown, infection, dehiscence, evisceration, delated healing, hemorrhage, hematoma

Hypocalcemia (low)

Calcium Deficit -Serum Level Less than 8.6 -Should be evaluated in combination with albumin levels

Hypokalemia (LOW K+) Patho:

Can occur from GI losses, medications, intestinal suctioning, poor diet intake, alternation of acid-base balance

Gastrointestinal Post-Op complicaitons

Constipation, paralytic ileum, bowel obstruction

Malignant hyperthermia: Treatment:

DANTROLENE = ANTIDOTE!

Neuro Post-Op complicaitons

Delirium & Stroke

Hypervolemia (FVE) Medical Management:

Diuretics -Reduce sodium & water reabsorption which enhances water loss at the kidneys Dialysis -If renal function is impaired and meds can't work- this removes the fluid out of the bloodstream Nutritional -diet restrictions of sodium

Hyperkalemia (High K+) Clinical Manifestations:

Effect on the heart - cardiac changes and dysrhythmias, muscle weakness, paresthesias, anxiety, GI issues, ECG changes, Metabolic or respiratory acidosis

Hypovolemia (FVD) Clinical Manifestations:

FVD can develop rapidly and its severity depends on the degree of fluid loss

Hypovolemia (FVD) Patho:

FVD results from loss of body fluids (fluid and electrolytes) & occurs more rapidly when coupled with decreased fluid intake

Hypervolemia (FVE)

Fluid Volume Excess/Overload

Hypovolemia

Fluid volume deficit

Hyponatremia Patho:

Imbalance of water, losses by vomiting, diarrhea, sweating, diuretics, adrenal insufficiency, certain medications, SIADH (soaked inside)

Hyperkalemia (High K+) Patho:

Impaired renal function, rapid administration of potassium (never give IV potassium fast- never IM or IV push), hypoaldosteronism, decreased renal excretion

Informed Subject

Informed consent should be in writing. It should contain the following -Explanation of procedure and risks -description of benefits and alternatives -An offer to answer questions about the procedure -Instructions that the patient may withdraw consent -A statement informing the patient if the protocol differs from the customary procedure

Hyponatremia

Low sodium (sodium loss, water gain) Sodium= NA+ (Serum Sodium Less then <135)

Trendelenburg

Padded shoulder braces & supine making T (surgery on the lower abdomen and pelvis)

Pre-operative Nursing

Period of time from when the decision to proceed with surgical intervention is made, to when the patient is transferred to the operating room table

Hypokalemia (LOW K+)

Potassium Deficit -Potassium= K+ -Serum Potassium Below 3.5 mEq/L

Hyperkalemia (High K+)

Potassium Excess -Potassium= K+ -Serum Potassium greater than 5.0 mEq/L

Hypervolemia (FVE) Clinical Manifestations:

Result from expansion of ECF and may include edema, distended jugular veins, crackles, prolonged steroid use, severe stress

Cardio Post-Op complicaitons

Shock, thrombophlebitis, DVT, Pulmonary embolism

Electrolyte Imbalances (Potassium)

The most abundant electrolyte in the ICF

Hypocalcemia (low) Patho:

The parathyroid glands are instrumental in regulating blood & body calcium levels.

Malignant hyperthermia

are inherited muscle disorder that is chemically induced by anesthetic agents (life-threatening)

A patient who is incompetent:

is an individual who is not autonomous and cannot give or withhold consent (individuals who are cognitively impaired, mentally ill, or neurologically incapacitated)

For kidney surgery:

lay on unaffected side

Malignant hyperthermia: S/S

muscle rigidity, tachycardia, fever, dysrhythmias, tachypnea, hypotension, cyanosis

Sims or lateral positon

patient placed on nonoperative side with an air pillow thick under the loin, or on a table with a kidney or back lift

peri-operative nursing

period of time that consists of the surgical experience, includes the PreOP, Intraop & Post-op phase of nursing care

Hypertonic solutions

should be administer slowly, small volumes are needed to elevate the concentration

Dorsal Recumbent

supine with arms out (abdominal surgeries)

Lithotomy

supine, arms open and extended, legs up, knees bent

Hypernatremia

too much salty sodium in the body sucks out the fluid inside cell

Functional Post-Op complicaitons

weakness, fatigue, functional decline