Medsurg Final Exam Review

Analgesics are categorized into three main groups:

(1) nonopioid analgesics, which include acetaminophen and the NSAIDs; (2) opioid analgesics such as morphine, hydrocodone, hydromorphone, fentanyl, and oxycodone; and (3) adjuvant analgesics (sometimes referred to as co-analgesics)

Pneumonia Interventions

improving gas exchange- oxygen therapy and incentive spirometry preventing airway obstruction- turn, cough, deep breathe preventing sepsis managing emphysema- thorocentesis if needed nutrition managing physical mobility prevent aspiration

Complications with Infection

inadequate antimicrobial therapy non compliance non adherence (accidental failure) blood stream infection sepsis

Acidosis Pathophysiology

increase in hydrogen can cause potassium imbalance which can effect nerve impulses, cardiac muscle and skeletal muscle

Hypervolemia

increased blood volume bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity <1.010. semi fowler's

Gout Assessment

joint inflammation chronic gout has tophi Labs: ESR, serum uric acid level, arthrocentesis, kidney function test

purulent fluid

pus or infected discharge from wound or incision

Culture Test

-method of multiplying organisms to reproduce in a predetermined culture media (solid agar plate or liquid) under laboratory controlled condition -this test is used to IDENTIFY the type of organism

Surgical Time Out

right patient right site right side right procedure

Laryngeal Trauma

Laryngeal trauma and damage occur with a crushing or direct-blow injury, fracture, or prolonged endotracheal intubation. Symptoms include difficulty breathing (dyspnea), inability to produce sound (aphonia), hoarseness, and subcutaneous emphysema (air present in the subcutaneous tissue). Bleeding from the airway (hemoptysis) may occur, depending on the location of the trauma. Management of patients with laryngeal injuries consists of assessing the effectiveness of GAS EXCHANGE and monitoring vital signs (including respiratory status and pulse oximetry) every 15 to 30 minutes. Maintaining a patent airway is a priority. Apply oxygen and humidification as prescribed to maintain adequate oxygen saturation. Signs of respiratory difficulty include tachypnea, nasal flaring, anxiety, sternal retraction, shortness of breath, restlessness, decreased oxygen saturation, decreased level of consciousness, and stridor. Assess the patient to recognize signs of respiratory difficulty (tachypnea, nasal flaring, anxiety, sternal retraction, shortness of breath, restlessness, decreased oxygen saturation, decreased level of consciousness, stridor). If any signs are present, respond by staying with the patient and instructing other trauma team members or the Rapid Response Team to prepare for an emergency intubation or tracheotomy. Surgical intervention is needed for lacerations of the mucous membranes, cartilage exposure, and cord paralysis. Laryngeal repair is performed as soon as possible to prevent laryngeal stenosis and to cover any exposed cartilage. An artificial airway may be needed.

Regional Anesthesia Risks

Leakage of Cerebrospinal Fluid from insertion site Reduced CSF can cause Post Op headache that can be treated with fluid, bedrest, and bloodpatch

Inflammatory Response

Stage 1: constriction of blood vessels, dilation of small vessels, pain, swelling, redness, heat, increase WBC, prevents blood loss Stage 2: Exudation with fluids/dead cells- serous, purulent, sanguineous (bloody) Stage 3: replacement of damaged tissue. Regeneration, becomes functional scarring

tension pneumothorax

a life-threatening complication of pneumothorax in which air continues to enter the pleural space during inspiration and does not exit during expiration (Loftus, 2014). As a result, air collects under pressure, completely collapsing the lung and compressing blood vessels, which limits blood return. This process leads to decreased filling of the heart and reduced cardiac output. If not promptly detected and treated, tension pneumothorax is quickly fatal.

Healthcare-associated infection (HAI)

an infection acquired within a healthcare setting during the delivery of medical care most common: wounds, UTI, respiratory tract, BSI

5. Does the CO2 or the HCO3 go the opposite direction of the pH?

this determines compensation. Once you determine acidosis or alkalosis and what system matches the pH then look at the other system. If the leftover system is out of range in the opposite column, then there is compensation by that system.

Hydrocodone

combination with nonopioids (Norco, Vicodin) limits its use to the treatment of mild-to-some moderate pain. It is the most commonly prescribed opioid analgesic in the United States and Canada, but its prescription for treatment of persistent pain (except for breakthrough dosing) should be evaluated carefully because of its ceiling on efficacy and safety related to the nonopioid constituent (ingredient). It is also available as a modified-release formulation (Zohydro, Hysingla) for chronic pain.

Hypocalcemia Interventions

supplement, vitamin D, increased magnesium, decreased phosphate, calcitrol, limit stimuli, IV calcium is needed

-centesis

surgical puncture

Viral Load

the amount of HIV present in an infected person's blood; affects transmission

normothemia

the appropriate body temp that's not too low and not too high

obstructive sleep apnea (OSA)

a breathing disruption during sleep that lasts at least 10 seconds and occurs a minimum of five times in an hour. The most common cause is upper airway obstruction by the soft palate or tongue. Factors that contribute to OSA include obesity, a large uvula, a short neck, smoking, enlarged tonsils or adenoids, and oropharyngeal edema.

Kaposi's sarcoma

a cancer that causes patches of abnormal tissue to grow under the skin, in the lining of the mouth, nose, and throat, or in other organs; frequently associated with HIV

Incentive Spirometer

a device used to force the client to concentrate on inspiration and promote full inflation of the lungs, while providing immediate feedback; used particularly after surgery and in lung disorders.

noncommunicable disease

a disease that is not transmitted by another person, a vector, or the environment

butterfly rash

a form of exacerbation disappears in remission stress management is crucial

Improving Gas Exchange and Reducing Carbon Dioxide Retention Planning: Expected Outcomes.

The patient with COPD is expected to attain and maintain GAS EXCHANGE at his or her usual baseline level. Indicators include that the patient: • Maintains SpO2 of at least 88% • Remains free from cyanosis • Maintains cognitive orientation • Coughs and clears secretions effectively • Maintains a respiratory rate and rhythm appropriate to his or her activity level

registered nurse first assistant

a member of the operating room team whose responsibilities may include handling tissue, providing exposure at the operative field, suturing, and maintaining hemostasis

Pseudoaddiction

a mistaken diagnosis of addictive disease

CDC HIV testing recommendations

adults- 1 screening between age 15-65 Annually for those with high risk HIV testing requires: interpretation, counseling, confidentiality

Use of Placebos

any medication or procedure, including surgery, which produces an effect in a patient because of its implicit or explicit intent, not because of its specific physical or chemical properties. A saline injection is one example of a placebo. Administration of a medication at a known subtherapeutic dose (e.g., 0.05 mg of morphine in an adult) is also considered a placebo. Placebos are appropriately used as controls in research evaluating the effects of a new medication.

cosmetic surgery

surgical procedures used for cosmetic purposes only ex: eye lift, face lift, forehead lifts, liposuction, collagen injections. Liposuction Revision of scars Rhinoplasty Blepharoplasty

Approximately 10 percent of people who have cutaneous lupus will develop

systemic lupus. However, it is likely that these people already had systemic lupus, with the skin rash as their main symptom.

Culture and Sensitivity Test

-Antibiotic Sensitivity vs Resistance -susceptibility means the microorganism can NOT grow if the antibiotic is present -resistant means the microorganism is able to grow -intermediate means a higher dose is needed to prevent growth

Bacteria

-living single cell -aerobic or anaerobic -can thrive in diverse and extreme conditions -have DNA and RNA -bacterial infections are mostly localized to one area but it can spread systematically -infection is caused by exposure or transmission

Implementing Dietary Restrictions

NPO - Patient not to ingest anything by mouth for 6 to 8 hours before surgery: -Decreases risk for aspiration -Give patients written/oral directions to stress adherence -Surgery can be canceled if instructions not followed A small sip with the morning beta blocker is allowed.

Smoking Cessation Drug Alerts

Teach adults using drugs for nicotine replacement therapy that smoking while taking these drugs greatly increases circulating nicotine levels and the risk for stroke or heart attack. Both bupropion and varenicline carry a black box warning that use of these drugs can cause manic behavior and hallucinations. These drugs also may unmask serious mental health issues. Teach patients prescribed either of these drugs and their families to report any change in behavior or thought processes to the prescriber immediately.

Levalbuterol (Xopenex)

Teach patient to monitor heart rate because excessive use causes tachycardia and other systemic symptoms. When taking any of these drugs with other inhaled drugs, teach patient to use it at least 5 minutes before the other inhaled drugs to allow the bronchodilation effect to increase the penetration of the other inhaled drugs. Teach patient the correct technique for using the MDI or DPI to ensure that the drug reaches the site of action

Inhalation Anthrax

inhalation anthrax (respiratory anthrax) is a bacterial infection caused by the gram-positive organism Bacillus anthracis. This organism lives as a spore in soil where grass-eating animals live and graze. Most cases of anthrax are on the skin (cutaneous)

Early HIV infection

initial infection- within 2 to 4 weeks experience flu like symptoms viral #'s bloodstream/genital tract over time feels well again- war going on with immune system

Spinal Anesthesia

inject local anesthetic agent into subarachnoid space used for surgeries of lower abdomen, perineum, and lower extremeties

hypotonic solutions

<300 mOsm/L D5W, Saline solutions <0.9%

Why do we want BP to be in range?

When the Blood pressure is high, the vessels have to work harder.

hyperplasia

overgrowth of tissues; therefore, the body can't perfuse as well. This is a result of high blood pressure

Pulmonary Embolism Treatment

oxygen therapy, thrombolytic drugs +/or anticoagulant

Holding area nurse

Manages the patient's care while the patient is in this area and initiates documentation on a perioperative nursing record.

Simple surgical procedure

skin and mucous membranes only cutting out a portion such as a mastectomy

Cations Electrolytes

sodium, potassium, calcium, magnesium

HIV Classification

0- initial HIV+ no AIDS illness 1- CD4 T cell count >500 or 29% no AIDS 2- CD4 T cell count >200-499 or 14-28% no AIDS 3- CD5 T cell count <200 or 14% OR >200 w/AIDS unknown- confirmed HIV+, AIDS, CD4 T cell count unknown

Hypercalcemia

>10.5 Decreased Cell Membrane Excitablity Caused by increased magnesium or decreased phosphorus, too many supplements, low TCT, GI problem (slow motility), calcium sparing diuretics "too many crossing guards so no one gets through"

Coagulation Tests

Prothrombin Time (PT)- evaluates ability to clot International Normalized Ratio (INR)- Ensures that results from a PT test are the same from one lab to another. Partial Prothrombin Time (PTT)- determines if blood thinning therapy is effective

Decline stage

-First signs of recovery -disease ends, becomes latent, to intermittently reoccurs

OA Health Promotion

-cutting calories -avoid injuries at a young age and stay active -goal is acceptable level of pain increased risk if patient has diabetes, Paget's, or sickle cell

Hypersensitivity reactions

1- Allergic Anaphylaxis 2- antibody 3- immune complex 4- delayed

What is a goal BP for over the age of 60?

150/90

OA Diagnosis

history and physical assessment and symptoms -family hx, work, disease -pain worse with activity and better with rest -X ray to see joint changes MRI/Ct to look at vertebra and knees labs aren't used to diagnose but can be used to screen

The priority collaborative problems for patients with PE include:

1. Hypoxemia due to mismatch of lung PERFUSION and alveolar GAS EXCHANGE with oxygenation 2. Hypotension due to inadequate circulation to the left ventricle 3. Potential for excessive bleeding due to anticoagulation or fibrinolytic therapy causing inadequate CLOTTING 4. Anxiety due to hypoxemia and life-threatening illness

Types of Immunity

1. Innate (General) 2. Adaptive (Specific)- natural and artificial which are active and passive

General Innate Immunity: WBC Basophil and Eosinphils

Basophil: 1% Function: prevents blood clots (contain heparin), responds to allergic reactions, stimulates general and allergic inflammation response Eosinophils: 1-4% Function: limits inflammatory reaction and prevents tissue damage, targets parasite larva

Magnesium Functions

1.8-2.6 Facilitates transfer and storing of energy Regulates Parathyroid hormone source: food absorbed in the GI tract

Pre-Op Overview

Begins as soon as the surgeon and patient agree on surgery. Complete a history and a physical. Gather baseline data. Order any pre-op testing. Assure patient understanding. Assess support system.

Isotonic Solutions

270-300 mOsm/L LR, NS

Acid Base Regulation

3 systems that maintain homeostasis - Buffer System (ongoing) - Respiratory (breathing) - Metabolic (reabsorption)

What should the nurse do if the O2Sat drops below 95%?

If you recognize that your patient's oxygen saturation drops below 95% (or below his or her presurgery baseline), immediately respond by notifying the surgeon or anesthesia provider. If the patient's condition continues to deteriorate or he or she becomes symptomatic, an emergency response is imperative.

Trachea—innominate artery fistula

A malpositioned tube causes its distal tip to push against the lateral wall of the tracheostomy. Continued pressure causes necrosis and erosion of the innominate artery. This is a medical emergency. The tracheostomy tube pulsates in synchrony with the heartbeat. There is heavy bleeding from the stoma. This is a life-threatening complication. Remove the tracheostomy tube immediately. Apply direct pressure to the innominate artery at the stoma site. Prepare the patient for immediate surgical repair. Correct the tube size, length, and midline position. Prevent pulling or tugging on the tracheostomy tube. Immediately notify the physician of the pulsating tube.

Pneumothorax and Hemothorax

A pneumothorax is air in the pleural space causing a loss of negative pressure in chest cavity, a rise in chest pressure, and a reduction in vital capacity, which can lead to a lung collapse (Arsbad et al., 2016). It is often caused by blunt chest trauma and may occur with some degree of hemothorax, which is bleeding into the chest cavity.

Pulmonary Embolism

A pulmonary embolism (PE) is a collection of particulate matter (solids, liquids, or air) that enters venous circulation and lodges in the pulmonary vessels. Large emboli obstruct pulmonary blood flow, leading to reduced GAS EXCHANGE, reduced oxygenation, pulmonary tissue hypoxia, decreased PERFUSION, and potential death. Any substance can cause an embolism, but a blood clot is the most common

Ankle-Brachial Index (ABI)

A ratio derived by dividing the ankle blood pressure by the brachial blood pressure; this calculation is used to assess the vascular status of the lower extremities. To obtain the ABI, a blood pressure cuff is applied to the lower extremities just above the malleoli. The systolic pressure is measured by Doppler ultrasound at both the dorsalis pedis and posterior tibial pulses. The higher of these two pressures is then divided by the higher of the two brachial pulses.

elective surgery

A surgical procedure that may be scheduled in advance, is not an emergency, and is discretionary on the part of the physician and patient cataract removal, hernia repair, hemorrhoidectomy, Total joint replacement

Potassium function

3.5-5.0 Nerve impulse conduction heart and muscle contraction body cannot store potassium more potassium inside the cell than outside the cell so a little change has a big effect

Fluid Overload Signs and Symptoms

Patient may report shortness of breath and cough; patient's blood pressure is elevated, and there is puffiness around the eyes and edema in dependent areas; patient's neck veins may be engorged, and nurse may hear moist breath sounds. lab values decreased because they are diluted

aneurysm risks and complications

Aneurysms can cause symptoms by exerting pressure on surrounding structures or by rupturing. Rupture is the most frequent complication and is life threatening because of abrupt and massive hemorrhagic shock results. Thrombi within the wall of an aneurysm can also be the source of emboli in distal arteries below the aneurysm. Atherosclerosis is the most common cause of aneurysms, with hypertension, hyperlipidemia, and cigarette smoking being contributing factors. Age, gender, and family history also play a role

Hypokalemia

<3.5 mEq/L Causes: vomiting, diarrhea, sweating, diuretics, wound drainage, NG drainage Reduces cell membrane excitability

water in the body

55-60% of adult TBW about 40L total interstitial fluid = 60L extracellular fluid= 40L

General innate immunity: WBC Neutrophil

55-70% of WBC count 2 types: Segs (Mature) 50-62% and Bands (Immature) 5% Function: phagocytosis, enzymatic digestion, recognizing non self cells Low count=neutropenia left shift is when the Segs are low and the Bands are high, which is not good. Segs are the phagocytic killers. Help heal damaged tissue; increase naturally. During an infection, these cells are released form the bone marrow and mature in the blood stream. ONE phagocytic event

IgG

75% of circulating. Heavily expressed on 2nd and subsequent exposure of an antigen

Venous Thromboembolism (VTE) Patho

A thrombus (also called a thrombosis) is a blood clot believed to result from an endothelial injury, venous stasis, or hypercoagulability. The thrombosis may be specifically attributable to one element, or it may involve all three elements. It is often associated with an inflammatory process. When a thrombus develops, IMMUNITY is altered, causing inflammation to occur around the clot, thickening of the vein wall, and possible embolization (the formation of an embolus). Phlebothrombosis is a thrombus without inflammation. Thrombophlebitis refers to a thrombus that is associated with inflammation. Thrombophlebitis can occur in superficial veins. However, it most frequently occurs in the deep veins of the lower extremities. Deep vein thrombophlebitis, commonly referred to as deep vein thrombosis (DVT), is the most common type of thrombophlebitis. It is more serious than superficial thrombophlebitis because it presents a greater risk for PE. With PE, a dislodged blood clot travels to the pulmonary artery—a medical emergency! DVT develops most often in the legs but can also occur in the upper arms as a result of increased use of central venous devices.

Respiratory Mechanism CO2

if buffers are not enough activated within minutes hypoventilation holds onto acid and hyperventilation gets rid of acid

Renal Mechanism HCO3

if respiratory system is overwhelmed takes hours most powerful response, very effective reabsorption or elimination of acid or base if needed

Active Immunity

immunity you develop after being exposed to an infection(natural) or vaccine(artificial)

Factors that affect the susceptible host

immunity, strength of infection, medication, broken skin, nutrition, broken skin, surgery

Respiratory Changes Associated With Aging: Risk for Infection

Effectiveness of the cilia decreases. Immunoglobulin A decreases. Alveolar macrophages are altered. Interventions: Encourage pulmonary hygiene and help patient actively maintain health and fitness. Regular pulmonary hygiene and overall fitness help maintain maximal functioning of the respiratory system and prevent illness.

Aging and the Immune System

Efficiency of immunity decreases with age: prevention is key when protecting from infections might not see a fever as quick pathogens don't get killed as much normal flora and secretions decrease more susceptible to infection, disorders, and cancer

COPD labs

ABG CBC CXR Sputum PFT

Acids vs Base

ACID: Liquids with a pH less than 7 more free hydrogen ions being released than bind CO2 BASE: liquids with a pH higher than 7 more hydrogen ions being bound than released HCO3

Tuberculosis

AIRBORNE bacteria An infectious disease that may affect almost all tissues of the body, especially the lungs

antibody

AKA immunoglobulins A protein the body produces to fight an antigen. ATTACH TO ANTIGENS

Human Papilloma Virus

Abbreviated HPV and also known as plantar warts; a virus that can infect the bottom of the foot and resembles small black dots, usually in clustered groups.

abdominal aneurysm

Abdominal aortic aneurysms (AAAs) account for most aneurysms, are commonly asymptomatic, and frequently rupture. Most of these are located between the renal arteries and the aortic bifurcation (dividing area).

Acid Production

Acid is a byproduct of the metabolism of CHO to CO2. CO2 -> breathing. metabolism of protein leads to sulfuric acid metabolism of fat leads to ketones incomplete breakdown of glucose leads to lactic acid cell destruction released acid from within the cell

thoracentesis follow up care

After thoracentesis, a chest x-ray is performed to rule out possible pneumothorax and mediastinal shift (shift of central thoracic structures toward one side). Monitor vital signs, and listen to the lungs for absent or reduced sounds on the affected side. Check the puncture site and dressing for leakage or bleeding. Assess for complications, such as reaccumulation of fluid in the pleural space, subcutaneous emphysema, infection, and tension pneumothorax. Urge the patient to breathe deeply to promote lung expansion. Document the procedure, including the patient's response; the volume and character of the fluid removed; any specimens sent to the laboratory; the location of the puncture site; and respiratory assessment findings before, during, and after the procedure. Teach the patient about the symptoms of a pneumothorax (partial or complete collapse of the lung), which can occur within the first 24 hours after a thoracentesis.

Allergies r/t respiratory system

Allergies to foods, dust, molds, pollen, bee stings, trees, grass, animal dander and saliva, or drugs can affect breathing. Ask the patient to describe specific allergic responses. For example, does he or she wheeze, have trouble breathing, cough, sneeze, or have rhinitis after exposure to the allergen? Has he or she ever been treated for an allergic response? If the patient has allergies, ask about the specific cause, treatment, and response to treatment.

Respiratory Changes Associated With Aging: Alveoli

Alveolar surface area decreases. Diffusion capacity decreases. Elastic recoil decreases. Bronchioles and alveolar ducts dilate. Ability to cough decreases. Airways close early. Interventions: Encourage vigorous pulmonary hygiene (i.e., encourage patient to turn, cough, and deep breathe) and use of incentive spirometry, especially if he or she is confined to bed or has had surgery. Potential for mechanical or infectious respiratory complications is increased in these situations .Encourage upright position. The upright position minimizes ventilation-perfusion mismatching.

Aneurysm Pathophysiology

An aneurysm forms when the middle layer (media) of the artery is weakened, producing a stretching effect in the inner layer (intima) and outer layers of the artery. As the artery widens, tension in the wall increases; and further widening occurs, thus enlarging the aneurysm and increasing the risk for arterial rupture. Elevated blood pressure can also increase the rate of aneurysmal enlargement and risk for early rupture. When dissecting aneurysms occur, the aneurysm enlarges, blood is lost, and blood flow to organs is diminished.

Oral Candidiasis (Thrush)

involves white curd-like growth on the mucous membranes of the mouth

Post-Op Wound Assessment

Assess the TISSUE INTEGRITY of the incision on a regular basis, at least every 8 hours, for redness, increased warmth, swelling, tenderness or COMFORT alterations, and the type and amount of drainage. Some drainage (e.g., 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 is a sign of possible dehiscence (discussed in the next paragraph), 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 surgical site infection (SSI) and must be reported to the surgeon.

Characteristics of Normal Breath Sounds

Bronchial (Tracheal)- Inspiration<Expiration Bronchovesicular (major bronchi)- Inspiration = Expiration Vesicular (peripheral lung fields)- Inspiration>Expiration

Chemistry: BASE

Bases are substances that binds to free hydrogen when dissolved in water, They decrease the amount of free hydrogen in that solution. Strength is measures by how easily is binds to hydrogen in that solution.

Stage 3 (Operative Anesthesia, Surgical Anesthesia)

Begins with generalized muscle relaxation and ends with loss of reflexes and depression of vital functions. The jaw is relaxed, and breathing is quiet and regular. The patient cannot hear. Sensations (i.e., to pain) are lost. Assist the anesthesiologist or CRNA with intubation. Place patient into operative position. Prepare (scrub) the patient's skin over the operative site as directed. Providing assistance helps promote smooth intubation and prevent injury. Performing procedures as soon as possible promotes time management to minimize total anesthesia time for the patient.

Stage 1 (Analgesia and Sedation, Relaxation)

Begins with induction and ends with loss of consciousness.Close operating room doors, dim the lights, and control traffic in the operating room.Avoiding external stimuli in the environment promotes relaxation.Patient feels drowsy and dizzy, has a reduced sensation to pain, and is amnesic.Position patient securely with safety belts.Using safety measures in stage 1 prepares for stage 2.Hearing is exaggerated.Keep discussions about the patient to a minimum.Being sensitive to the patient maintains his or her dignity.

Base production

Bicarbonate: -breakdown of carbonic acid -GI absorption of ingested bicarbonate -Pancreatic production of bicarbonate -kidney reabsorption of filtered bicarbonate -movement of cellular bicarbonate into the ECF

Regional Anesthesia

Blocks multiple peripheral nerves in specific body region: Field Nerve Spinal Epidural

Bronchospasm and Asthma

Bronchospasm is 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.

The abbreviation for High Blood Pressure

HTN (hypertension)

tophi with chronic gout

Hard, painless nodule (tophi) over metatarsophalangeal joint of first toe. Tophi are collections of sodium urate crystals due to chronic gout in and around the joint that cause extreme swelling and joint deformity. They sometimes burst with a chalky discharge.

Opioid Analgesics

management of moderate-to-severe nociceptive types of pain such as postoperative, surgical, trauma, and burn pain morphine, fentanyl, hydromorphone, oxycodone, oxymorphone, and hydrocodone.

Gold Classification of COPD Severity

CLASSPULMONARY FUNCTION TEST RESULTS GOLD 1: MildFEV1 ≥80% of predicted GOLD 2: ModerateFEV1 50% to 79% of predicted GOLD 3: SevereFEV1 30% to 49% of predicted GOLD 4: Very severeFEV1 <30% of predicted

4. Match the CO2 or the HCO3 with the pH

CO2 = respiratory problem HCO3= metabolic problem

Respiratory Acidosis Causes

CO2 retention, which leads to impaired respiratory function: respiratory depression, inadequate chest expansion, airway obstruction, reduced tissue perfusion

Imaging and Diagnostics for Surgery

CXR- looking for impression, infiltrates, heart shape and size EKG- looking at O2 demands, arrhythmias, how the heart is functioning

Post-Op Leg & Foot Exercises

Calf Pumping Quad Setting Foot Circles Hip/Knee Movements

Low-Flow Oxygen Delivery Systems

Low-flow systems include the nasal cannula, simple facemask, partial rebreather mask, and nonrebreather mask (Table 28-1). These systems are easy to use and fairly comfortable, but the amount of oxygen delivered varies and depends on the patient's breathing pattern. The oxygen is diluted with room air (21% oxygen), which lowers the amount actually inspired.

Chest Tube

Catheter inserted through the thorax into the chest cavity for removing air or fluid; used after chest or heart surgery or pneumothorax.

Bronchodilators

Cause bronchodilation through relaxing bronchiolar smooth muscle by binding to and activating pulmonary beta2 receptors.

Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary diseases (COPD) interfere with airflow and GAS EXCHANGE. These disorders include emphysema and chronic bronchitis. Although these are separate disorders with different pathologic processes, many patients with emphysema also have chronic bronchitis

fibromyalgia syndrome

Chronic pain syndrome Not an inflammatory disease Pain, stiffness, tenderness at certain areas of neck, upper chest, trunk, low back, extremities arthritis and other comorbidities commonly present

Pulmonary Embolism S/S

Classic Symptoms • Dyspnea, sudden onset • Sharp, stabbing chest pain • Apprehension, restlessness • Feeling of impending doom • Cough • Hemoptysis Signs • Tachypnea • Crackles • Pleural friction rub • Tachycardia • S3 or S4 heart sound • Diaphoresis • Fever, low-grade • Petechiae over chest and axillae • Decreased arterial oxygen saturation (SaO2

lymphatic system

Composed of a network of vessels, ducts, nodes, and organs. Provides defense against infection.

Thoracic Outlet Syndrome

Compression of subclavian artery by rib or muscle that is more common in women and those who have to keep arms moving or above their heads (e.g., golfers, swimmers); also present with trauma; causes neck, arm, and shoulder pain with numbness and possible cyanosis Treatment: Physical therapy for exercise program; avoiding aggravating positions; surgery as last resort for severe painHealth teaching about avoiding activities and positions that aggravate pain; monitor for new signs and symptoms; neurovascular assessments; postoperative care if needed.

Cricothyroidotomy

Cricothyroidotomy is an emergency procedure performed by emergency medical personnel as a stab wound at the cricothyroid membrane between the thyroid cartilage and the cricoid cartilage (see Fig. 27-3). Any hollow tube—but preferably a tracheostomy tube—can be placed through the opening to hold this airway open until a tracheotomy can be performed. This procedure is used when it is the only way to secure an airway. Another emergency procedure to bypass an obstruction is the insertion of a 14-gauge needle or a very small endotracheal tube directly into the cricoid space to allow airflow into and out of the lungs.

Asthma Risks

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 or upper respiratory illness and for unknown reasons.

IgE

Involved in Allergy response and parasite infection

potassium supplements

K-Dur and K-lyte

Dehydration Nursing Diagnosis

Deficient Fluid volume Impaired oral mucous membrane Risk for shock Impaired tissue perfusion

Serum Sickness

Definition: Group of symptoms occurring after receiving serum or certain drugs. (ex: Penicillin, other antibiotics, Thiazides Signs/Symptoms: (7-12 days after exposure) fever, arthralgia, rash(itchy bruise color), malaise, enlarged lymph nodes Diagnosis: WBC, sed rate increase. Medical Treatment: Antipyretics, analgesics, antihistamines, epinephrine. Nursing Care: Assessment, meds, education.

Inspiration (inhale)

Diaphragm contracts, pulling muscle down; intercostal muscles contract, elevating chest wall and expanding volume of chest, lowering pressure in lungs, pulling in air

Breathing Exercises

Diaphragmatic or Abdominal Breathing • If you can do so comfortably, lie on your back with your knees bent. If you cannot lie comfortably, perform this exercise while sitting in a chair. • Place your hands or a book on your abdomen to create resistance. • Begin breathing from your abdomen while keeping your chest still. You can tell if you are breathing correctly if your hands or the book rises and falls accordingly. Pursed-Lip Breathing • Close your mouth and breathe in through your nose. • Purse your lips as you would to whistle. Breathe out slowly through your mouth, without puffing your cheeks. Spend at least twice the amount of time it took you to breathe in. • Use your abdominal muscles to squeeze out every bit of air you can. • Remember to use pursed-lip breathing during any physical activity. Always inhale before beginning the activity and exhale while performing it. Never hold your breath.

diagnostic surgery

Done to provide data for a diagnosis of the problem (e.g., mass biopsy, exploratory laparotomy). Breast biopsy Exploratory laparotomy Arthroscopy

VTE Assessment

During the nursing assessment, one point is given for each of nine characteristics, which include: • Active cancer, paralysis, or casting of an extremity • Bedridden for more than 3 days • Major surgery with general anesthesia during the previous 3 months • Localized tenderness along the deep venous system • Swelling of the entire leg • Calf swelling of greater than 3 cm larger when compared with the other leg • Pitting edema in one leg • Dilated superficial veins in one leg • Previously documented DVT A score of 2 or more indicates that a DVT is likely to occur.

Causes of Plaque Formation

Genetics Older age Lifestyle habits: Smoking High-cholesterol/high-fat diet Sedentary lifestyle Other medical problems: Hypertension Diabetes Hyperlipidemia- high cholesterol and triglycerides Renal failure

Doffing PPE

Gloves • Eyewear • Gown • Mask

Droplet precautions PPE

Gloves • Gown • Surgical Mask • Face shield or goggles if splash is possible

Donning PPE

Gown • Mask • Eyewear • Gloves

never give potassium

IV push

Nerve blocks

Injected around a nerve trunk to produce lack of sensation, such as an extremity

insensible fluid loss

Occurs daily through lungs and skin--cannot be measured for accurate output

Normal Plasma Values

Osmolarity 270-300 mOsm Sodium 136-145 Potassium 3.5-5.0 Chloride 96-109 Calcium 9.0-10.5 Magnesium 1.8-2.6

Pertussis

Pertussis is a respiratory infection caused by the bacterium Bordetella pertussis. It is highly contagious and spreads easily from person to person via respiratory droplets. Once considered a childhood disease, is it making a comeback in adults, perhaps because of decreasing

Correct Site Surgery

SCIP Measure Marking the surgical site is done by physician or PA immediately before intra-op and is verified with the patient. An arm band is used for internal organs.

Hydromorphone (Dilaudid)

The drug is often used as an alternative to morphine, especially for acute pain, most likely because the two drugs produce similar analgesia and have comparable side effects. It is a first- or second-choice opioid (after morphine) for postoperative management via IV patient-controlled analgesia (PCA) and is available in a once-daily modified-release oral formulation (Exalgo) for long-term opioid treatment.

Tuberculosis Diagnosis

There are several methods to test for TB. In addition to chest x-ray, sputum cultures of blood or respiratory secretions can be tested. The most accurate and rapid test for TB is the fully automated nucleic acid amplification test (NAAT) used on respiratory secretions. Results are available in less than 2 hours.

Drain & Tubes

Tubes: NG, ET, foley Drains: JP, Penrose, Hemovac, chest tube Vascular access: must have IV access

Calcium Channel Blockers

Verapamil Diltiazem Nifedipine Amlodipine Felodipine

Airway Obstruction Interventions

When the obstruction is caused by the tongue falling back or excessive secretions, slightly extend the patient's head and neck and insert a nasal or an oral airway. Suction to remove any obstructing secretions. If the obstruction is caused by a foreign body, perform abdominal thrusts. Upper airway obstruction may require emergency procedures such as cricothyroidotomy, endotracheal intubation, or tracheotomy to improve GAS EXCHANGE. Laryngoscopy may be performed to determine the cause of obstruction or to remove foreign bodies.

pathogenicity

ability of a microorganism to cause disease

immunocompetent

ability to develop an immune response or recognize antigens and respond to them

OA Joint Effusions

abnormal accumulation of excess joint fluid swelling mild to severe with inflammation pain can be dull to sharp leading to immobilization stiffness decreases ROM don't confuse with edema

Mycobacterium tuberculosis

anergy- false negative

Biologic Response Modifiers (BRMs)

neutralize biologic activity of tumor necrosis factor avoid if diagnosed with MS or TB glucocorticoids immunosuppresive agents analgesic drugs need to also take calcium and vitamin D

Cytomegalovirus

nonspecific illness that usually causes disease when the immune system is compromised. widespread throughout body, eyes, lungs, GI, brain, no cure

6. Are the PO2 and the O2 saturation normal?

normal PaO@ is 80-100 Normal O2 is 95-100 if either are below normal, there is evidence of hypoxemia

Blood pressure Regulation

baroreceptors in the heart will sense the increase or decrease in BP. This will stimulate the vasoconstriction or vasodilation of arteries. Other ways include: fluid balance, RAAS, vascular autoregulation

1. Is the pH normal?

normal range is 7.35-7.45 acidosis is less than 7.4 alkalosis is greater than 7.4

Tolerance

normal response that occurs with regular administration of an opioid and consists of a decrease in one or more effects of the opioid (e.g., decreased analgesia, sedation, or respiratory depression). Like physical dependence, tolerance is not the same as addictive disease

Epidural analgesia

can be delivered by intermittent bolus technique, continuous infusion, or patient-controlled epidural analgesia (PCEA) with or without continuous infusion. The most commonly administered analgesics by the epidural route are the opioids morphine, hydromorphone, and fentanyl in combination with a long-acting local anesthetic such as bupivacaine (Marcaine) or ropivacaine (Naropin). This multimodal approach allows lower doses of both the opioid and local anesthetic and produces fewer side effects. A single epidural injection of preservative-free morphine (Duramorph) is effective for about 24 hours. An extended-release formulation of preservative-free epidural morphine (DepoDur) is effective for 48 hours.

natural killer cells (NK cells)

cytotoxic against non self cells without sensitization (cancer, virus)

What is the best early indicator of fluid overload?

daily weights

Alkalosis

decrease in free hydrogen ions pH> 7.45

calcium and magnesium

direct relationship

droplet precautions

droplets can travel up to 3 feet ex: Strep, flu, pneumonia, rubella, mumps Regular mask needed

Fluid Overload Evaluation

edema improved, weight returns to baseline Identify signs of fluid overload Take diuretics as ordered Prevention

Tapentadol

is appropriate for both acute and chronic pain. Major benefits of tapentadol are that it has no active metabolites and a significantly more favorable side effect profile (particularly GI effects) compared with opioid analgesics.

leukocytes

migrate in the blood system and lymphatic system to help clear out waste and work like a security system

If balance is disturbed, the delivery of what is also disturbed?

nutrients and electrolytes

inpatient surgery

operative procedures performed on persons admitted to a hospital and expected to remain for a period of time

Patient cohorting

pairing patients with the same illnesses caused by the same organism to prevent spread of infection

solute

particles dissolved or suspended in water (nutrients/electrolytes)

Body fluid pH

the measure of hydrogen ions within the body fluid body works to fund balance through control of free hydrogen by production and elimination

clinical stage

the stage in which the signs and symptoms of a disease arise and are most prominent

incubation stage

time interval between the entry of an infectious agent in the host and the onset of symptoms

Dual Mechanism Analgesics

tramadol (Ultram) and tapentadol (Nucynta)

Prions

transmissible pathogenic agents affecting the brain; long incubation, rapid onset, fatal

Care of the Patient Receiving Mechanical Ventilation

• Assess the patient's respiratory status and GAS EXCHANGE at least every 4 hours for the first 24 hours and then as needed: • Take vital signs at least every 4 hours. • Assess the patient's color (especially lips and nail beds). • Observe the patient's chest for bilateral expansion. • Assess the placement of the nasotracheal or endotracheal tube. • Obtain pulse oximetry reading. • Evaluate ABGs as available. • Maintain head of the bed more than 30 degrees when patient is supine to prevent aspiration and ventilator-associated pneumonia. • Document pertinent observations in the patient's medical record. • Check at least every 8 hours to be sure that the ventilator setting is as prescribed. • Check to be sure that alarms are set (especially low-pressure and low-exhaled volume). • If the patient is on PEEP, observe the peak airway pressure dial to determine the proper level of PEEP. • Check the exhaled volume digital display to be sure that the patient is receiving the prescribed tidal volume. • Empty ventilator tubings when moisture collects. Never empty fluid in the tubing back into the cascade. • Ensure humidity by keeping delivered air temperature maintained at body temperature. • Be sure the tracheostomy cuff (or endotracheal cuff) is adequately inflated to ensure tidal volume. • Auscultate the lungs for crackles, wheezes, equal breath sounds, and decreased or absent breath sounds. • Check the patient's need for tracheal, oral, or nasal suctioning every 2 hours and suction as needed. • Assess the patient's mouth around the ET tube for pressure injuries. • Perform mouth care every 2 hours. • Change tracheostomy tube holder or tape or ET tube holder or tape as needed: • Carefully move the oral ET tube to the opposite side of the mouth once daily to prevent ulcers. • Provide tracheostomy care every 8 hours. • Assess ventilated patients for GI distress (diarrhea, constipation, tarry stools). • Maintain accurate intake and output records to monitor fluid balance. • Turn the patient at least every 2 hours and get the patient out of bed as prescribed to promote pulmonary hygiene and prevent complications of immobility. • Schedule treatments and nursing care at intervals for rest. • Monitor the patient's progress on current ventilator settings and make appropriate changes as indicated. • Monitor the patient for the effectiveness of mechanical ventilation in terms of his or her physiologic and psychological status. • Monitor for adverse effects of mechanical ventilation: infection, barotrauma, reduced cardiac output. • Position the patient to facilitate ventilation-perfusion (V̇/Q̇) matching ("good lung down"), as appropriate. • Monitor the effects of ventilator changes on GAS EXCHANGE and the patient's subjective response. • Monitor readiness to wean. • Explain all procedures and treatments; provide access to a call light; visit the patient frequently. • Provide a method of communication. Request consultation with a speech-language pathologist for assistance, if necessary. • Initiate relaxation techniques, as appropriate. • Administer muscle-paralyzing agents, sedatives, and narcotic analgesics, as prescribed. • Include the patient and family whenever possible (especially during suctioning and tracheostomy care).

Telangiectasias

(spider veins) are dilated intradermal veins less than 1 to 3 mm in diameter that are visible on the skin surface. Most patients are not bothered by them but may consider them unattractive. Most telangiectasias do not develop into the more severe varicose vein disease.

PAD Diagnostic Studies

-Angiography: CT scan or MRI with contrast -Ultrasound: typically done before an angiography; doppler or vascular -Ankle Brachial Index: BP on all 4 extremities -Exercise Tolerance Testing

Diagnosis of AIDS

-CD4+ T-cell count <200 cells/mm3 OR -HIV w/ an opportunistic infection present Western Blot

restorative surgery

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

Antibody Response Graph

-secondary response reacts much quicker

6 steps to ABG analysis

1. is the pH normal? 2. Is the CO2 normal? 3. IS the HCO3 normal? 4. Match the CO2 or the HCO3 with the pH 5. Does the CO2 or the HCO3 go the opposite direction of the pH? 6. Are the PO2 and O2 saturation normal?

what blood pressure is considered pre-hypertension? This is when we need to start watching

130-139 systolic

Weight of Water

1L = 1kg = 2.2 lbs

IgM

1st antibody formed by new sensitized B cell activates complement pathway

The Patient Recovering from Pneumonia

Ask whether the patient has had any of these: • New-onset confusion • Chills • Fever • Persistent cough • Dyspnea • Wheezing • Hemoptysis • Increased sputum production • Chest discomfort • Increasing fatigue • Any other symptoms that have failed to resolve Assess the patient for: • Fever • Diaphoresis • Cyanosis, especially around the mouth or conjunctiva • Dyspnea, tachypnea, or tachycardia • Adventitious or abnormal breath sounds • Weakness

Epidural Anesthetic Drug Alert

Assess patients receiving epidural local anesthetic for their ability to bend their knees and lift their buttocks off the mattress (if not prohibited by surgical procedure). Ask them to point to any areas of numbness and tingling. Mild, transient lower-extremity motor weakness and orthostatic hypotension may be present, necessitating assistance with ambulation. Most undesirable effects can be managed with a reduction in local anesthetic dose. Promptly report areas of numbness outside of the surgical site, inability to bear weight, and severe hypotension to the anesthesia provider. Do not delegate assessment of local anesthetic effects to unlicensed assistive personnel!

Asthma

Asthma is a chronic disease in which reversible airway obstruction occurs intermittently, reducing airflow. Airway obstruction occurs by both inflammation and airway tissue sensitivity (hyperresponsiveness) with bronchoconstriction. Inflammation obstructs the airway lumens (i.e., the insides). Airway hyperresponsiveness and constriction of bronchial smooth muscle narrow the tubular structure of the airways. Airway inflammation and sensitivity can trigger bronchiolar constriction, and many adults with asthma have both problems. Severe airway obstruction reduces GAS EXCHANGE and can be fatal.

Asthma in older Adults

Asthma occurs as a new disorder in about 3% of adults older than 55 years, and another 3% of adults older than 60 years have asthma as a continuing chronic disorder (Arjona, 2015). Lung and airway changes as a part of aging make breathing problems more serious in the older adult. One problem related to aging is a decrease in the sensitivity of beta-adrenergic receptors. When stimulated, these receptors relax smooth muscle and cause bronchodilation. As these receptors become less sensitive, they no longer respond as quickly or as strongly to agonists (epinephrine, dopamine) and beta-adrenergic drugs, which are often used as rescue therapy during an acute asthma attack. Thus teaching older patients how to avoid asthma attacks and how to correctly use preventive drug therapy is a nursing priority.

Nedocromil (Tilade) (inhaled drug)

Blocks the leukotriene receptor, preventing the inflammatory mediator from stimulating inflammation. Purpose is to prevent asthma attack triggered by inflammation or allergens.

Acid Base Balance

Body aims to maintain fluids as slightly acidic which is achieved by balancing the rate of hydrogen production and elimination

Respiratory Changes Associated With Aging: Exercise Tolerance

Body's response to hypoxia and hypercarbia decreases. Interventions: Assess for subtle manifestations of hypoxia. Early assessment helps prevent complications.

Local Anesthesia

Briefly disrupts sensory nerve impulse transmission from specific body area/region Delivered topically and by local infiltration Patient remains conscious, able to follow instructions

Other Arterial Health Problems

Burger's Disease- claudication in the feet and lower extremeties. brought on by cold, stress, smoking, caffeine Raynaud's Disease- brought on by cold, stress, smoking, caffeine Subclavian Steal Thoracic Outlet Syndrome

COPD Etiology and Genetic Risk

Cigarette smoking Alpha1-antitrypsin (AAT) deficiency Air pollution

Asthma Drug Therapy

Control therapy drugs are used to reduce airway sensitivity (responsiveness) to prevent asthma attacks from occurring to maintain GAS EXCHANGE. They are used every day, regardless of symptoms. Reliever drugs (also called rescue drugs) are 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. Therapy involves the use of bronchodilators and various drug types to reduce inflammation. Some drugs reduce the asthma response, and other drugs actually prevent it. Combination drugs are two agents from different classes combined together for better response

Home Care for HTN

EDUCATE the patient and provide reliable resources Home BP cuff and log Scale if weight loss is suggested Dietary teaching, dietician if needed Stress management, counselor if needed Tobacco cessation, provide resources if necessary Limit alcohol, provide resources if necessary

Hypokalemia Assessment

EKG changes, telemetry, lower HR, weak pulse, lower RR, constipation, fatigue, weakness, lethargy, altered LOC

Foods and Drugs That Interfere With Warfarin (Coumadin)

Eat only small amounts of foods rich in vitamin K each day, including any of these: • Broccoli • Cauliflower • Spinach • Kale • Other green leafy vegetables • Brussels sprouts • Cabbage • Liver If possible, avoid: • Allopurinol • NSAIDs • Acetaminophen • Vitamin E • Histamine blockers • Cholesterol-reducing drugs • Antibiotics • Oral contraceptives • Antidepressants • Thyroid drugs • Antifungal agents • Other anticoagulants • Corticosteroids • Herbs, such as St. John's wort, garlic, ginseng, Ginkgo biloba

radical surgery

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

Aneurysms of the Peripheral Arteries

Femoral and popliteal aneurysms DO NOT PALPATE Symptoms: Limb ischemia Diminished or absent pulses Cool to cold skin Pain Treatment: Surgery Postoperative care: Monitor for pain

What three processes help regulate fluid and electrolyte balance?

Filtration, Diffusion, Osmosis

Respiratory Patient History Considerations

Gender Health Considerations: Women, especially smokers, have greater bronchial responsiveness (i.e., bronchial hyperreactivity) and larger airways than men. This factor increases the risk for a more rapid decline in lung function as a woman ages, especially in women who were or are smokers. Be sure to measure gas exchange adequacy with pulse oximetry when assessing women. Cultural/Spiritual Considerations: Compared with white adults, black adults and others with dark skin usually show a lower oxygen saturation (3% to 5% lower) as measured by pulse oximetry; this results from deeper coloration of the nail bed and does not reflect true oxygen status. Use additional respiratory assessment techniques to assess gas exchange adequacy in adults with dark skin

Airborne PPE Order

HH Gown N95 Gloves

Epidural Blocks

Injected into the epidural space, outside the dura mater of the spinal cord Used for surgeries of the abdomen and lower extremities

Rhonchus (rhonchi)

Lower-pitched, coarse, continuous snoring sounds Arise from the large airways Thick, tenacious secretions Sputum production Obstruction by foreign body Tumors

Modified-release opioids Drug Alert

Modified-release opioids should never be crushed, broken, or chewed because doing so alters the formulation of the drug and can result in adverse events, including death from respiratory depression if consumed. Teach the patient to swallow the drug whole and allow the "time-release" function of the drug to take effect. Intact modified-release tablets may be administered rectally in some patients who cannot swallow.

Oxycodone hydrochloride and acetaminophen (Percocet, Endocet, Oxycocet) Monitor for..

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

Oxycodone hydrochloride and aspirin (Percodan, Endodan, Oxycodan) Monitor for..

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

Butorphanol tartrate (Stadol) Monitor for..

Monitor neurologic status and for changes in level of consciousness because this medication can cause increased intracranial pressure. Monitor for respiratory depression.

Calcium Channel Blockers Nursing Implications Common examples of calcium channel blockers: • Verapamil (Calan, Isoptin, Nu-Verap ) • Amlodipine (Norvasc) • Diltiazem (Cardizem)

Monitor pulse and BP before taking each day because the drug slows SA and AV conduction, which decreases HR and vasodilation and causes decreased BP. Teach patients to avoid grapefruit juice and grapefruit while taking calcium channel blockers because grapefruit and its juice can enhance the action of the drug, causing organ dysfunction or death.

Morphine sulfate (Epimorph, Statex), and Hydromorphone hydrochloride (Dilaudid) Monitor for..

Monitor respiratory rate and blood pressure because respiratory depression can be severe and require medical intervention. Monitor GI motility and urine output because constipation and urinary retention can occur.

Expiration (exhale)

Muscles relax; diaphragm resumes dome shape; intercostal muscles allow chest to lower, resulting in increase of pressure in chest and expulsion of air

Fluid Overload Implementation

Patient Safety Restore fluid balance Provide supportive care until balance is restored Prevention

Intestinal Preparation

Performed to prevent injury to colon; reduce number of intestinal bacteria -Enema or laxative Risk for falls.

Neuropathic Pain (Abnormal Pain Processing)

Peripheral or central nervous system: nerve fibers, spinal cord, and higher central nervous system Poorly localized Shooting, burning, fiery, shocklike, tingling, painful numbness Phantom limb pain, postmastectomy pain, nerve compression HIV-related pain, diabetic neuropathy, postherpetic neuralgia, chemotherapy-induced neuropathies, cancer-related nerve injury, radiculopathies

Impact of Unrelieved Pain

Physiologic ImpactQuality-of-Life Impact • Prolongs stress response • Increases heart rate, blood pressure, and oxygen demand • Decreases GI motility • Causes immobility • Decreases immune response • Delays healing • Poorly managed acute pain increases risk for development of chronic pain • Interferes with ADLs • Causes anxiety, depression, hopelessness, fear, anger, and sleeplessness • Impairs family, work, and social relationships Financial Impact • Costs Americans billions of dollars per year • Increases length of hospital stay • Leads to lost income and productivity

Alkalosis interventions

Prevent further losses of hydrogen, potassium, calcium, chloride ions Restore fluid balance Monitor changes, provide safety Modify or stop gastric suctioning, IV solutions with base, drugs that promote hydrogen ion excretion antiemetic and stop diuretics

Cystic Fibrosis Interventions

Preventive/maintenance therapy involves the use of positive expiratory pressure, active cycle of breathing technique, and an individualized exercise program. Exacerbation therapy is needed when the patient with CF has increased chest congestion, reduced activity tolerance, increased or new-onset crackles, and a 10% decrease in FEV1. Other symptoms include increased sputum production with bloody or purulent sputum, increased coughing, decreased appetite, weight loss, fatigue, decreased SpO2, and chest muscle retractions. Often infection is present, with fever, increased lung infiltrate on x-ray, and an elevated white blood cell count. Gene therapy for CF is available for use in patients with specific gene mutations The surgical management of the patient with CF is lung transplantation.

Acid-Base (ROME)

R-espiratory O-pposite M-etabolic E-qual

HIV Testing

Rapid Antigen Test: Detects Antibodies -Home test by using mucosal exudate 3rd Gen Test: Accurate w/ long window period -ELISA enzyme linked immunosorbent assay IgG -Western Blot confirms HIV result 4th Gen Test: Duo antigen/antibody test most tests take 21-28 days to determine result

Pasero Opioid-Induced Sedation Scale (POSS) With Interventions*

S = Sleep, easy to arouse Acceptable; no action necessary; may increase opioid dose if needed. 1 = Awake and alert Acceptable; no action necessary; may increase opioid dose if needed. 2 = Slightly drowsy, easily aroused Acceptable; no action necessary; may increase opioid dose if needed. 3 = Frequently drowsy, arousable, drifts off to sleep during conversation Unacceptable; monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory; decrease opioid dose 25% to 50%1 or notify primary2 or anesthesia provider for orders; consider administering a nonsedating, opioid-sparing nonopioid such as acetaminophen or a NSAID if not contraindicated; ask patient to take deep breaths every 15-30 minutes. 4 = Somnolent; minimal or no response to verbal and physical stimulation Unacceptable; stop opioid; consider administering naloxone3,4; call Rapid Response Team (code blue); stay with patient, stimulate, and support respiration as indicated by patient status; notify primary2 or anesthesia provider; monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory.

ADH abnormalities

SIADH- too much Diabetes insipidus- not enough

Dehydration Planning

SMART outcomes Restore fluid balance Prevent injury such as oral sores

ARBs

Sartan Sisters candesartan valsartan losartan

What are the most common lab tests used to help determine fluid and electrolyte imbalance?

Serum electrolyte concentration, blood urea nitrogen (BUN), and serum osmolality

What causes an increased neutrophil count?

Smoking and certain medications

Sputum Specimens

Sputum specimens can help identify organisms or abnormal cells. Sputum culture and sensitivity analyses identify bacterial infection and determine which specific antibiotics will be most effective.

Blood Culture

Supplies: 2 sets of culture bottles, 2 sets of non sterile gloves, alcohol pads, 2 10mL syringes, 2 needles, 2 chlorhexidine, 2 sets of cultures 1. Locate vein to use, scrub with friction with chlorhexidine for 30 seconds and allow to dry 2. apply tourniquet, insert needle, withdraw 10mL of blood then insert 5mL in each bottle. ALWAYS AEROBIC FIRST

SCIP measures

Surgical Care Improvement Project - organization of passengers that wasn't too improve surgery care. - Anti biotic within one HR from incision, antibiotics DC within 24 hr, urinary cath removal 1- 2 days

Heberden's nodes

Swelling of distal interphalangeal finger joints, characteristic of osteoarthritis genetic don't confuse with RA

Albuterol (ProAir, Proventil, Ventolin) (inhaled drug)

Teach patients to carry drug with them at all times because it can stop or reduce life-threatening bronchoconstriction.

Alveoli

Terminal air sacs that constitute the gas exchange surface of the lungs.

Pneumonia in the Older Adult

The older adult with pneumonia has weakness, fatigue (which can lead to falls), lethargy, confusion, and poor appetite. Fever and cough may be absent, but hypoxemia is often present. The most common symptom of pneumonia in the older-adult patient is a change in COGNITION with acute confusion from hypoxia. The WBC count may not be elevated until the infection is severe. Waiting to treat the disease until more typical symptoms appear greatly increases the risk for sepsis and death. In the older adult, the chest x-ray is essential for early diagnosis because pneumonia symptoms are often vague

When can a pt. speak with a trach?

The patient can speak when there is a cuffless tube, when a fenestrated tracheostomy tube is in place, and when the fenestrated tube is capped or covered

Centers for Disease Control and Prevention (CDC)

The primary federal agency that conducts and supports public health activities in the United States. The CDC is part of the US Department of Health and Human Services.

Facial Trauma

The priority action when caring for a patient with facial trauma is airway assessment for GAS EXCHANGE. Signs of airway obstruction are stridor, shortness of breath, dyspnea, anxiety, restlessness, hypoxia, hypercarbia (elevated blood levels of carbon dioxide), decreased oxygen saturation, cyanosis, and loss of consciousness.

Metabolic Acidosis Interventions

Treat cause Fluid replacement (0.9 NS or 0.45 NS) Monitor for dysrhythmias Monitor K+ levels insulin if DKA Anti diarrheal give HCO3

Respiratory Changes Associated With Aging: Pulmonary Vasculature

Vascular resistance to blood flow through pulmonary vascular system increases. Pulmonary capillary blood volume decreases. Risk for hypoxia increases. Interventions: Assess patient's level of consciousness and cognition. Patient can become confused during acute respiratory conditions because of reduced oxygen levels in the brain.

Wound Culture Swab

Verify Order Explain procedure Gather supplies: swab kit, 10mL syringe, normal saline, non sterile gloves, specimen bag, sterile gauze 1. Hand Hygiene 2. Don gloves 3. Irrigate wound with normal saline then wipe gently with sterile gauze 4. Moisten swab with normal saline 5. Identify 1cm area- stay away from edges 6. Apply minimal pressure to express wound fluid turning the swab stick between your fingers 7. Insert swab into container 8. Remove gloves, hand hygiene 9. Label time, date, location

NANDA: Risk for Infection Nursing Interventions

Vitals, Head to toe assessment, assess mucous membranes Monitor labs Screen visitors Inspect Promote- nutrition, I+Os Teach- patient and family

Diaphragm

a dome-shaped, muscular partition separating the thorax from the abdomen in mammals. It plays a major role in breathing, as its contraction increases the volume of the thorax and so inflates the lungs.

Surgical management of an aneurysm

aneurysmectomy endovascular stent grafts

Dehydration Evaluation

assess signs and symptoms intake and output wound drainage daily weights lung sounds confusion or lethargy prevent

Home oxygen therapy is provided in one of three ways:

compressed gas in a tank or a cylinder, liquid oxygen in a reservoir, or an oxygen concentrator.

RA symptoms: Late

deformities mod to severe pain morning stiffness osteoporosis severe fatigue anemia weight loss sub q nodules neuropathy vasculitis major organs can be affected from ischemia

Lab Tests regarding fluid balance

dehydration - values go up bc more concentrated overload- values drop because less concentrated and more dilute

insufflation

delivery of pressurized air or gas into a cavity, chamber, or organ to allow visual examination, remove an obstruction, or apply medication. May cause post op pain

calcium and phosphorus

indirect relationship

opportunist infection

infection that develops in a person with a weak immune system; this can be dangerous for patients with a low CD4 T cell count caused by organisms that are present as a part of the body microbiome

Raynaud's phenomenon

intermittent attacks of vasoconstriction in the fingers and toes often triggered by exposure to cold (the digits will go from pink, to blue, to white, back to pink as blood flow is restricted and then restarted)

MRSA

methicillin-resistant staphylococcus aureus most common bacteria on skin, perineum, nose most common HAI bc of contamination S/S: fever, chills, redness, warmth, cellulitis, pain, drainage, non healing wound diagnosed by a culture source Risks: invasive device, hospitalized, long term care C&S report used to determine antibiotic

The Sodium Potassium Pump

more sodium outside and more potassium inside required energy so active transport

contact precautions

practices used to prevent spread of disease by direct or indirect contact ex: C diff, MRSA, VRE, RSV, Scabies, Varicella

"Never Events"

preventable errors, which may include falls, urinary tract infections from improper use of catheters, and pressure ulcers

Gout

systemic disease in which rate crystals deposit in joints and other tissues causing inflammation. form of arthritis males get it from mother affects middle age to older men and postmenopausal women primary is most common and caused by error in purine metabolism secondary is when there is excessive uric acid in the blood caused by crash diets, chemo, older age, obesity, and diuretic overuse

Sodium Source

table salt, processed foods CDC recommends less than 2G a day Absorbed in Gi tract Regulatory mechanism is the kidneys

laparoscopy

visual examination of the abdomen

uretoscopy

visual examination of the ureter

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

Complications of stent repair

• Conversion to open surgical repair • Bleeding • Aneurysm rupture • Peripheral embolization • Misplacement of the stent graft • Endoleak

The patient with TB is expected to maintain a patent and adequate airway. Indicators of adequacy are:

• Effective cough • Able to expectorate secretions • Adequate GAS EXCHANGE • Absence of cyanosis

Contact precautions PPE

• Gloves • Gown • Face shield or goggles if splash is possible

Secondary HTN Causes

• Kidney disease • Primary aldosteronism • Pheochromocytoma • Cushing's disease • Coarctation of the aorta • Brain tumors • Encephalitis • Pregnancy • Drugs: • Estrogen (e.g., oral contraceptives) • Glucocorticoids • Mineralocorticoids • Sympathomimetics

Risk factors for development of VTE include:

• Obesity • 40 years of age or older • Cancer • Decreased mobility or immobility • Spinal cord injury • History of VTE, DVT, PE, varicose veins, or edema • Oral contraceptives use • Smoking • Decreased cardiac output • Hip fracture or total hip or total knee surgery

Those with acute arterial insufficiency often present with the "six P's" of ischemia:

• Pain • Pallor • Pulselessness • Paresthesia • Paralysis • Poikilothermy (coolness)

DVT Prevention

•SCDs/TED hose, •Early /often ambulation •Heparin/lovenox Leg exercises***

ACE Inhibitors

"PRIL" Captopril, Enalapril, Afosiopril Antihypertensive. Blocks ACE in lungs from converting angiotensin I to angiotensin II (powerful vasoconstrictor). Decreases BP, Decreased Aldosterone secretions, Sodium and fluid loss. Check BP before giving (hypotension) *Orthostatic Hypotension

Titration

(dose increases or decreases) of the opioid dose is usually required at the start and throughout the course of treatment when opioids are administered. Whereas patients with cancer pain most often are titrated upward over time for progressive pain, patients with acute pain, particularly postoperative pain, are eventually titrated downward as pain resolves.

Opioid antagonist

(e.g., naloxone [Narcan], naltrexone [Revia]) are drugs that also bind to opioid receptors but produce no analgesia. If an antagonist is present, it competes with opioid molecules for binding sites on the opioid receptors and has the potential to block analgesia and other effects. They are used most often to reverse opioid effects such as excessive sedation and respiratory depression.

RA Diagnosis

-ESR elevation -Serum rheumatoid factor -Synovial fluid analysis -X-rays (often inconclusive) -Antinuclear antibody -CBC, WBC

cells of immunity

-all cells come from bone marrow 1. Stem cell divides into lymphocytes or myeloid progenitor 2. Lymphoid Stem cell breaks into lymphocytes and myeloid progenitor breaks into granulocytes 3. Lymphocytes breaks into B cell, T cell, NK cell and Granulocytes breaks into neutrophil, eosinophil, basophil, mast cell, and monocyte 4. B cell breaks into plasma cell and memory cell, T cell breaks into Th cell and Tc cell, monocyte breaks into dendrite and macrophage

Nursing Care and Treatment for Lupus

-avoid UV sun exposure -use mild skin care products -steroids creams for skin rashes -avoid crowds -report infections, edema, dyspnea, and chest pain promptly -topical drugs -hydroxchloroquine -tylenol or NSAID -chronic steroids -immunosupressive agents -belimumab

Virus

-nonliving, until it has a host to thrive -smallest organism out of all microbes: DNA or RNA -can only replicate in other living things

Anticonvulsants

(also called antiepileptic drugs [AEDs] when used for seizure management) produce analgesia by blocking sodium and calcium channels in the CNS, thereby diminishing the transmission of pain. The gabapentinoids gabapentin (Neurontin) and pregabalin (Lyrica) are recommended as first-line analgesics for persistent neuropathic pain. Gabapentin may also be administered as an epidural injection. These drugs are increasingly being added to postoperative treatment plans to address the neuropathic component of surgical pain. Primary side effects are sedation and dizziness, which are usually transient and most notable during the titration phase of treatment.

PAD pulse locations

*Palpate pulses in both legs frequently *Posterior tibial pulse is MOST sensitive and specific indicator of arterial function *Pedal pulse is NOT very RELIABLE because it can't always be felt in all people

RA Drug Therapy

1. NSAID's (non-steroidal ant-inflammatory drug) 2. DMARD's (disease-modifying anti-rheumatic drug) 3. BRM's (biologic response modifiers) 4. Analegesic medications (oral & topical) 5. Steroids (oral or injection)

Fluid Volume Deficit (FVD)

A decrease in intravascular, interstitial, and/or intracellular fluid in the body.

HTN in men vs women

A higher percentage of men than women have hypertension until 45 years of age. From ages 45 to 64, the percentages of men and women with hypertension are similar. After age 64, women have a higher percentage of the disease

2 Types of Specific Immunity

Antibody Mediated and Cell Mediated

Transplant Rejection

Caused by General and Specific Immunity Hyper-acute: S/S are flu like, fever, weight gain, pain, fatigue, urinary retention. Immediate Acute- 1 week to 3 months. Labs or biopsy to determine. S/S differ. Chronic- inflammation and scarring

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 and improve GAS EXCHANGE

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.

Sinus Infections

Cold, flu, or allergy that leads to heavy mucus production, can lead to an infection in the sinuses. Thick greenish mucus, headaches and sinus pain. Doctor can prescribe antibiotics to cure.

curative surgery

Cures; alleviates a problem (e.g., appendectomy). Cholecystectomy Appendectomy Hysterectomy

Noninvasive Positive-Pressure Ventilation

Noninvasive positive-pressure ventilation (NPPV) is a type of noninvasive ventilation (NIV). This technique uses positive pressure to keep alveoli open and improve GAS EXCHANGE without the need for and dangers of intubation (Bajaj et al., 2015). It is used to manage dyspnea, hypercarbia and acute exacerbations of chronic obstructive pulmonary disease (COPD), cardiogenic pulmonary edema, and acute asthma attacks

Visceral Pain

Organs and the linings of the body cavities Poorly localized Diffuse, deep cramping or pressure, sharp, stabbing Chest tubes, abdominal tubes and drains, bladder distention or spasms, intestinal distention Pancreatitis, liver metastases, colitis, appendicitis

Rupturing AAA

Patients with a rupturing AAA are critically ill and are at risk for hypovolemic shock caused by hemorrhage. Signs and symptoms include hypotension, diaphoresis, decreased level of consciousness, oliguria (scant urine output), loss of pulses distal to the rupture, and dysrhythmias. Retroperitoneal hemorrhage is manifested by hematomas in the flanks (lower back). Rupture into the abdominal cavity causes abdominal distention.

Acute Peripheral Arterial Occlusion Interventions

Patients with an acute arterial occlusion describe severe pain below the level of the occlusion that occurs even at rest. The affected extremity is cool or cold, pulseless, and mottled. Small areas on the toes may be blackened or gangrenous due to lack of PERFUSION. The primary health care provider must initiate treatment promptly to avoid permanent damage or loss of an extremity. Anticoagulant therapy with unfractionated heparin (UFH, Hepalean) is usually the first intervention to prevent further clot formation. The patient may undergo angiography. A surgical thrombectomy or embolectomy with local anesthesia may be performed to remove the occlusion. The health care provider makes a small incision, which is followed by an arteriotomy (a surgical opening into an artery). A catheter is inserted into the artery to retrieve the embolus. It may be necessary to close the artery with a synthetic or autologous (patient's own blood vessel) patch graft.

Pneumonia Etiology

Pneumonia develops when a patient's IMMUNITY cannot overcome the invading organisms (Arsbad et al., 2016). Organisms from the environment (especially after natural disasters), from invasive devices, equipment and supplies, or other people can invade the body. Pneumonia can be caused by bacteria, viruses, mycoplasmas, fungi, rickettsiae, protozoa, and helminths (worms). Noninfectious causes of pneumonia include inhalation of toxic gases, chemical fumes, and smoke and aspiration of water, food, fluid (including saliva), and vomitus. Pneumonia can be categorized as community-acquired (CAP), hospital-acquired (HAP), health care-acquired (HCAP) or ventilator-associated (VAP)

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.

Airborne Precautions PPE

Private, negative air pressure room • Gloves • Gown • N95 or respirator • Face shield or goggles if splash is possible

Sample Goals for Clients with HTN

The patient will verbalize plan of care for hypertension The patient will take hypertension medication as prescribed seven days per week Patient will consume no more than 2 G sodium per day Patient will engage in moderate physical activity for at least 40 min at least four times per week Patient will reduce consumption of red meat from 5 times weekly to no more than two times weekly Patient will reduce number of cigarettes smoked daily to no more than 10 cigarettes per day

Informed Consent

The physician explains everything while the nurse serves as a witness. Have to have a certified translator if needed.

Sexual Transmission of HIV

Unprotected sex with an HIV infected partner is most common mode of transmission. Gender Risk: Male to unprotected female Sexual practice risk is anal intercourse cART must be started 24-36 hours of exposure

Pre-Op Lab Assessment

Urinalysis Blood Type and Screen CBC Clotting Studies Basic Metabolic Panel

Hypercalcemia Assessment

low HR, low BP, telemetry, slow and shallow RR, lethargy, weakness, decreased DTR, slow movement, bone pain, slow GI, increased risk for kidney stones

essential (primary) hypertension causes

• Family history of hypertension • African-American ethnicity • Hyperlipidemia • Smoking • Older than 60 years or postmenopausal • Excessive sodium and caffeine intake • Overweight/obesity • Physical inactivity • Excessive alcohol intake • Low potassium, calcium, or magnesium intake • Excessive and continuous stress

Specific Considerations When Planning Care for the Older Preoperative Patient

• Greater incidence of chronic illness (e.g., hypertension, diabetes, cardiac) • Greater incidence of malnutrition and dehydration • More allergies • Increased abnormal laboratory values (anemia, low albumin level) • Increased incidence of impaired self-care abilities • Inadequate support systems • Decreased ability to withstand the stress of surgery and anesthesia • Increased risk for cardiopulmonary complications after surgery • Risk for a change in mental status when admitted (e.g., related to unfamiliar surroundings, change in routine, drugs) • Increased risk for a fall and resultant injury • Mobility changes

Risk Factors for Atherosclerosis

• Low HDL-C • High LDL-C • Increased triglycerides • Genetic predisposition • Diabetes mellitus • Obesity • Sedentary lifestyle • Smoking • Stress • African-American or Hispanic ethnicity • Older adult

Common Causes of Oxygenation Failure

• Low atmospheric oxygen concentration: • High altitudes, closed spaces, smoke inhalation, carbon monoxide poisoning • Pneumonia • Congestive heart failure with pulmonary edema • Pulmonary embolism (PE) • Acute respiratory distress syndrome (ARDS) • Interstitial pneumonitis-fibrosis • Abnormal hemoglobin • Hypovolemic shock • Hypoventilation • Complications of nitroprusside therapy: • Thiocyanate toxicity, methemoglobinemia

The patient with COPD is expected to achieve and maintain a body weight within 10% of ideal. Indicators include that the patient:

• Maintains an appropriate weight/height ratio • Maintains serum albumin or prealbumin within the normal range

Nursing Focus on the Older-Adult Chronic Respiratory Disorder

• Provide rest periods between activities such as bathing, meals, and ambulation. • Place the patient in an upright position for meals to prevent aspiration. • Encourage nutritional fluid intake after the meal to promote increased calorie intake. • Schedule drugs around routine activities to increase adherence to drug therapy. • Arrange chairs in strategic locations to allow the patient with dyspnea to stop and rest while walking. • Urge the patient to notify the primary health care provider promptly for any symptoms of infection. • Encourage the patient to receive the pneumococcal vaccine and to have an annual influenza vaccination. • For patients who are prescribed home oxygen, keep tubing coiled when walking to reduce the risk for tripping.

Causes of upper airway obstruction include:

• Tongue edema (surgery, trauma, angioedema as an allergic response to a drug) • Tongue occlusion (e.g., loss of gag reflex, loss of muscle tone, unconsciousness, coma) • Laryngeal edema • Peritonsillar and pharyngeal abscess • Head and neck cancer • Thick secretions • Stroke and cerebral edema • Smoke inhalation edema • Facial, tracheal, or laryngeal trauma • Foreign-body aspiration • Burns of the head or neck area • Anaphylaxis

Pain Assessment

•Location(s): Ask the patient to state or point to the area(s) of pain on the body • Localized pain is confined to the site of origin. • Projected pain is diffuse around the site of origin and is not well localized. • Referred pain is felt in an area distant from the site of painful stimuli. • Radiating pain is felt along a specific nerve or nerves. • Intensity: Ask the patient to rate the severity of the pain using a reliable and valid assessment tool. • Quality: Ask the patient to describe how the pain and discomfort feels. • Onset and duration: Ask the patient when the pain started and whether it is constant or intermittent. • Aggravating and relieving factors: Ask the patient what makes the pain worse and what makes it better. • Effect of pain on function and quality of life: The effect of pain on the ability to perform recovery activities should be evaluated regularly. • Comfort-function (pain intensity) outcomes: For patients with acute pain, identify expected short-term functional outcomes. • Other information: Consider the patient's culture, past pain experiences, and pertinent medical history such as comorbidities.

What is hypersensitivity?

•Overactive allergic response •Immunity with inflammation occurring in response to presence of an antigen that the patient usually has been previously exposed •Cause: Antigen with antibody response •Mild to life threatening •4 basic types: Type I, II, III, IV •Pneumonic:

What is a goal BP?

140/90

Hypomagnesemia

<1.8 Causes are inadequate intake of Mg, less Calcium, alcohol, poor diet Increased cell membrane excitability

Intubation and Ventilation

Always assess patients being mechanically ventilated for indications of respiratory distress and poor GAS EXCHANGE. When symptoms of respiratory distress develop during mechanical ventilation, respond by immediately removing the ventilator and providing ventilation with a bag-valve-mask device. This action allows quick determination of whether the problem is with the ventilator or the patient.Monitor patients at risk for airway obstruction and impaired ventilation. When you recognize the need for emergency intubation and ventilation, respond by bringing the code (or "crash") cart, airway equipment box, and suction equipment (often already on the code cart) to the bedside. Maintain a patent airway through positioning (head-tilt, chin-lift) and the insertion of an oral or nasopharyngeal airway until the patient is intubated. Delivering manual breaths with a bag-valve-mask may also be required. Assess intubated patients to recognize indications of decreased GAS EXCHANGE. When these indications are present, respond by checking for DOPE: displaced tube, obstructed tube (most often with secretions), pneumothorax, and equipment problems.

pandemic

Disease that occurs over a wide geographic area and affects a very high proportion of the population.

Droplet PPE Order

HH Mask Googles Gloves

Management of Dehiscence

If dehiscence (wound opening) occurs, apply a sterile nonadherent (e.g., Telfa) or saline dressing to the wound and notify the surgeon. Instruct the patient to bend the knees and avoid coughing. A wound that becomes infected dehisces by itself, or it may be opened by the surgeon through an incision and drainage (I&D) procedure. In either case the wound is left open and is treated as described previously.

COPD Physical Assessment

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 patient often sits in a forward-bending posture with the arms held forward, a position known as the orthopneic or tripod position. 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. 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. 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. Examine the patient's chest for the presence of a "barrel chest". 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 signs 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.

transdermal fentanyl Drug Alert

Teach patients using transdermal fentanyl not to apply heat (e.g., hot packs, heating pads) directly over the patch because heat increases absorption of the drug and can result in adverse events, including death from fentanyl-induced respiratory depression. Ask patients about the presence of patches on admission and document and communicate this information to other members of the interdisciplinary health care team.

Asthma Drug Alerts

Teach the patient with asthma to always carry the relief drug inhaler with him or her and to ensure that enough drug remains in the inhaler to provide a quick dose when needed. LABAs should never be prescribed as the only drug therapy for asthma and are not to be used during an acute asthma attack or bronchospasm. Teach the patient to use these control drugs daily as prescribed, even when no symptoms are present, and to use a SABA to relieve acute symptoms. Any patient using these drugs must be monitored closely. Anti-inflammatory drug therapy for asthma is for prevention or control of asthma. They are not effective in reversing symptoms during an asthma attack and should not be used alone as reliever drugs. Teach patients to take anti-inflammatory asthma drugs on a scheduled basis, even when no symptoms are present.

Anticoagulant Discharge instructions

The VTE Core Measures and the Joint Commission's National Patient Safety Goals require that patients be given written discharge instructions about anticoagulant therapy that address: • Drug compliance issues (need to take drug as prescribed) • Dietary advice (e.g., foods to avoid) • Follow-up monitoring (e.g., Coumadin clinic, INR testing) • Information about potential for adverse drug reactions/interactions (e.g., bleeding, bruising)

Ventilators and Older Adults

The older patient, especially one who has smoked or who has a chronic lung problem such as COPD, is at risk for ventilator dependence and failure to wean. Age-related changes, such as chest wall stiffness, reduced ventilatory muscle strength, and decreased lung elasticity, reduce the likelihood of weaning. The usual symptoms of ventilatory failure—hypoxemia and hypercarbia—may be less obvious in the older adult. Use other clinical measures of GAS EXCHANGE and oxygenation, such as a change in mental status, to determine breathing effectiveness

atherosclerosis

Type of arteriosclerosis Plaque buildup inside arteries Plaque may be stable or unstable

Bronchial blood supply

blood supply for the conducting airways and support structures - warms and humidifies incoming air - drains into pulmonary vein

Hyperkalemia Assessment

dysrhythmias, increased DTR, twitching, cramping, irritated, agitated, seizures, decreased urine output, Respiratory failure

Metabolic Compensation

more powerful effective changes in ECF once they start The imbalance must be prolonged more than 24 hours to be triggered most effective The kidneys can compensate for imbalances that are respiratory in origin.

-ectomy

surgical removal

Comorbidity

the co-occurrence of two or more disorders in a single individual

Oxycodone

used to treat all types of pain. In combination with acetaminophen or ibuprofen, it is appropriate for mild-to-some moderate pain. Single-entity, short-acting (OxyIR) and modified-release (OxyContin) oxycodone formulations are used in patients with moderate-to-severe chronic pain. It has been used successfully as part of a multimodal treatment plan for postoperative pain as well

prodromal stage

vague feelings of discomfort; nonspecific complaints

Intraoperative Safety

monitoring patient condition, maintaining sterile environment, procurement of specimens, fluid monitoring, equipment/supply counts, safety control measures

Latent Period of Infection

-infectious agent has invaded a host, and found conditions hospitable to replicate -*NOT* contagious yet

Bloodborne pathogens

Disease-causing microorganisms carried in the body by blood or body fluids, such as hepatitis and HIV.

Contact PPE order

HH gown face shield gloves

Calcium hormones

PTH is released if calcium is low TCT is released is calcium is too high calcitrol inhibits release of calcitonin

antigens

a pathogen with a foreign protein or allergen that causes your immune system to react (ex:bacteria, virus, pollen)

Compensation Cont.

pH is normal = fully compensated CO2 OR HCO3 are abnormal = uncompensated CO2 AND HCO3 are BOTH abnormal = partially compensated

Glomerular Filtration Rate (GFR)

the amount of filtrate formed per minute by the two kidneys combined. The lower the rate, the lower the kidney function... which results in increased BP.

Flow of Surgery

1. Patient into OR room moved to OR bed 2. Anesthesia is administered 3. Positioned, Padded, and prepped 4. Timeout 5. Surgery begins 6. Following Surgery, patient is taken to PACU

Passive immunity

*temporary* immunity you acquire from someone or something else natural- breast milk artificial- serum medicine ex: tetanus shot

Causes of Acidosis

- Diarrhea - Renal Failure - Diabetes - Starvation - Aspirin - Cocaine - Ileostomy - Biliary drainage

PAD surgical interventions

-must meet certain criteria Arterial Revascularization- is the surgical procedure most commonly used to increase arterial blood flow in an affected limb. Graft materials for bypasses are selected on an individual basis. For outflow procedures, the preferred graft material is the patient's own (autogenous) saphenous vein. However, some patients experience coronary artery disease and may need this vein for coronary artery bypass. When the saphenous vein is not usable, the cephalic or basilic arm veins may be used. Grafts made of synthetic materials have also been used when autogenous veins were not available.

Beta Blockers

-olol: slow HR, decrease vasoconstriction, decrease O2 consumption. Used in: HF, HTN, HR control, angina, migraine. AE: HF, bronchospasm, dizzy, constipation, suppresses hypoglycemia indicators. Contra: asthma, bradycardia, SSS. Nursing: check HR before giving. Teach: take med at bedtime, do not stop abruptly. Propranolol=essential tremors, Parkinsons

Staph vs. MRSA

...

The Supraglottic Method of Swallowing

1. Place yourself in an upright, preferably out-of-bed, position. 2. Clear your throat. 3. Take a deep breath. 4. Place to 1 teaspoon of food into your mouth. 5. Hold your breath or "bear down" (Valsalva maneuver). 6. Swallow twice. 7. Release your breath and clear your throat. 8. Swallow twice again. 9. Breathe normally.

Coarse crackles Low-pitched crackles

Lower-pitched, coarse, rattling sounds caused by fluid or secretions in large airways; likely to change with coughing or suctioning Bronchitis Pneumonia Tumors Pulmonary edema

Metabolic Alkalosis Causes

Actual: Excess HCO3(overproduction or under elimination) relative: underproduction of acids or over elimination of acids (CO2)the

older patients are at greater risk for....

Dehydration. less total body water decreased thirst sensation Impaired motor function Drug therapy, such as diuretics, antihypertensives, laxatives

Complementary Interventions for HTN

Garlic, but effectiveness is controversial

Smoking Patient Considerations

Gender Health Considerations: Lesbian women, gay men, bisexual men and women, and transgender (LGBT) adults report higher rates of smoking compared with their heterosexual counterparts (ALA, 2015). Therefore screening for smoking and tobacco-related health conditions is especially important when working with LGBT patients. Cultural/Spiritual Considerations: The prevalence of smoking is higher among African Americans, blue-collar workers, and less-educated adults than in the overall North American population. It is highest among Native American and Native Canadian Indians. Development of culturally appropriate smoking-cessation programs and research examining barriers to cessation in these populations may help reduce this disparity.

Graft occlusion (blockage)

Graft occlusion (blockage) is a postoperative emergency that can occur within the first 24 hours after arterial revascularization. Monitor the patient for and report severe continuous and aching pain, which may be the first indicator of postoperative graft occlusion and ischemia. Many people experience a throbbing pain caused by the increased blood flow to the extremity. Because this alteration in comfort is different from that of ischemic pain, be sure to assess the type of pain that is experienced. Pain from occlusion may be masked by patient-controlled analgesia (PCA). Some patients have ischemic pain that is not relieved by PCA. Monitor the patency of the graft by checking the extremity every 15 minutes for the first hour and then hourly for changes in color, temperature, and pulse intensity. Compare the operative leg with the unaffected one. If the operative leg feels cold; becomes pale, ashen, or cyanotic; or has a decreased or absent pulse, contact the surgeon immediately!

High-Flow Oxygen Delivery Systems

High-flow systems (Table 28-2) include the Venturi mask, aerosol mask, face tent, Vapotherm high-flow nasal cannula, tracheostomy collar, and T-piece. These devices deliver an accurate oxygen level when properly fitted, with oxygen concentrations from 24% to 100% at 8 to 15 L/min. More recently, high-flow nasal cannulas (HFNCs) such as Vapotherm are more widely used for precise temperature and oxygen control along with humidification. With use of these devices at liter flows of 40 to 60 L/min, an FiO2 approaching that of a nonrebreather system can be achieved.

SLE Diagnosis

History, physical assessment, lab tests, similar to RA, CBC, renal function, MRI, X ray, CT, urinalysis

Pathophysiology of Common Signs and Symptoms of Pneumonia

Increased respiratory rate/dyspnea Stimulation of chemoreceptors Increased work of breathing as a result of decreased lung compliance Stimulation of J receptors Anxiety Pain Hypoxemia Alveolar consolidation Pulmonary capillary shunting CoughFluid accumulation in the receptors of the trachea, bronchi, and bronchiolesPurulent, blood-tinged, or rust-colored sputumA result of the inflammatory process in which fluid from the pulmonary capillaries and red blood cells moves into the alveoliFeverPhagocytes release pyrogens that cause the hypothalamus to increase body temperaturePleuritic chest discomfortInflammation of the parietal pleura causes pain on inspiration

Nursing Implications: Isoniazid (INH, Hydrazide, PDP-Isoniazid ) Kills actively growing mycobacteria outside the cell and inhibits the growth of dormant bacteria inside macrophages and caseating granulomas

Instruct the patient to avoid antacids and to take the drug on an empty stomach (1 hour before or 2 hours after meals) to prevent slowing of drug absorption in the GI tract. Teach the patient to take a daily multiple vitamin that contains the B-complex vitamins while on this drug because the drug can deplete the body of this vitamin. Remind the patient to avoid drinking alcoholic beverages while on this drug because the liver-damaging effects of this drug are potentiated by drinking alcohol. Tell 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, which are signs and symptoms of liver toxicity or failure.

Ketorolac tromethamine (Toradol) Monitor for..

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

Anti-diuretic hormone (ADH)

Released from posterior pituitary gland when blood osmolarity is increased Focus is on regulating water through reabsorption or excretion: -when ADH is released, more water is held -when ADH is suppressed, more water is released Also called vasopressin

Importance of Immunity

Surveillance- scans and recognizes or destroys bad cells Defense- protects by eliminating threats Homeostasis-removed damaged or dead cells

CBC Values

WBC: 5k-10k Hgb: males 14-18, females 12-16 Hct: males 42-52%, females 37-47% Plts: 150k-400k RBC: males 4.7-5.1, females 4.2-5.4

RA symptoms: Early

bilateral joint inflammation low fever fatigue weakness anorexia paresthesia

Acidosis

excess of free hydrogen ions pH <7.35

solvent

fluid (water/liquid)

Fluid Balance

optimal body function depends on fluids and electrolytes and homeostasis

arthroscopy

visual examination of a joint

virulence

How much damage is caused by the pathogen

Two basic principles of providing effective interprofessional collaborative care are

(1) preventing pain and (2) maintaining a level of pain control that allows the patient to function and have an acceptable quality of life. Accomplishment of these desired outcomes may require the mainstay analgesic to be administered on a scheduled around-the-clock (ATC) basis rather than PRN ("as needed") to maintain stable analgesic levels. ATC dosing regimens are designed to control pain for patients who report it being present 12 hours or more during a 24-hour period, such as that associated with most chronic syndromes and pain during the first 24 to 48 hours after surgery or other tissue injury. PRN dosing of analgesics is appropriate for intermittent pain such as before painful procedures and breakthrough pain (additional pain that "breaks through" the pain being managed by the mainstay analgesic), for which supplemental doses of analgesic are provided.

Continuous peripheral nerve block

(also called perineural regional analgesia) offers an alternative with longer-lasting analgesia. A continuous peripheral nerve block involves establishment by an anesthesia provider of an initial block followed by placement of a catheter through which an infusion of local anesthetic is administered continuously, with or without PCA capability. When PCA capability is added, this is referred to as patient-controlled regional analgesia (PCRA). Just as with epidural and intrathecal analgesia, nurses are responsible for monitoring and managing the therapy

Emergency thrombectomy

(removal of the clot), which the surgeon may perform at the bedside, is the most common treatment for acute graft occlusion. Thrombectomy is associated with excellent results in prosthetic grafts. Results of thrombectomy in autogenous vein grafts are not as successful and often necessitate graft revision and even replacement. Local intra-arterial thrombolytic (clot-dissolving) therapy with an agent such as tissue plasminogen activator (t-PA) or an infusion of a platelet inhibitor such as abciximab (ReoPro) may be used for acute graft occlusions. This therapy is provided in select settings in which health care providers are experts in its use. Other antiplatelet drugs such as the glycoprotein IIb/IIIa inhibitors tirofiban (Aggrastat) and eptifibatide (Integrilin) may be used as alternatives. The health care provider considers these therapies when the surgical alternative (e.g., thrombectomy with or without graft revision or replacement) carries high morbidity or mortality rates or when surgery for this type of occlusion has traditionally yielded poor results. Closely assess the patient for manifestations of bleeding if thrombolytics are used.

Obtaining a Specimen Culture

*ALWAYS GET SPECIMEN BEFORE ANTIBIOTICS* -collection of specimen must be done by nurse -performed whenever an infection is suspected -labeled with: name date time source and location initials

PAD Assessment

*Assess for LOSS OF HAIR on the lower calf, ankle, & foot *Assess for DRY, SCALY, DUSKY, PALE, or MOTTLED skin *Assess for thickened toenails *Assess for muscle atrophy *Assess for coolness of limbs and Cyanosis *Pallor may occur if extremity is ELEVATED *Dependent Rubor (redness) can occur when extremity is LOWERED *Assess nail beds, soles of hands & feet, mucus membranes for cyanosis in dark skin

PAD Ulcers

*Note early signs of ulcer formation or complete signs of ulcer formation *ARTERIAL ulcers: Painful & develop on the toes, between the toes, or on the upper aspect of the foot -with prolonged occlusion, the toes can become gangrenous -these ulcers are typically small & round & have a punches out appearance with well-defined borders

Causes of Alkalosis

- Hyperventilation (release of too much CO2) - Ingestion of too much antacid, - Prolonged vomiting with loss of stomach acids

Type I hypersensitivity allergens

- Inhaled (plant pollens, ragweed, animal dander, grass) - Ingested (foods, food additives, drugs) - Injected (bee venom, drugs, biological substances) - Skin/mucous membrane contact (latex, pollens, foods, environmental)

RA Etiology

- Patient's own immune system attacks the joint tissue, antibody-complement complex results in intra-articular and systemic inflammation - Corticosteroids decrease immune system Affects women more than men Stress links to exacerbations

Acid Base Imbalance

-changes shape and reduces function of hormones and enzymes -changes distribution of other electrolytes -changes excitability of membranes -decreases the effectiveness of many drugs

Functions of water

-transports nutrients and electrolytes, facilitates removal of waste -moistens mucous membranes -lubricates joints -regulates body temp -prevents constipation

Signs and Symptoms of sepsis

-Lethargy or irritability -Hypotonia -Hypotension -Pallor, duskiness, or cyanosis -Cool and clammy skin -Temperature instability -Feeding intolerance -Hyperbilirubinemia -Tachycardia followed by apnea/bradycardia

COPD Surgical Management

-Lung transplant -SIngle organ transplant -Organs are in short supply Lung Volume Reduction Surgery -Removal of nonfunctioning section of lungs -Allows expansion of functional lung tissue -Decreases dyspnea for 'selected' patients

Toxoplasmosis encephalitis

-acquired through contact w/ contaminated cat feces, ingestion of infected/undercooked meat -assess: subtle changes in mental status, neurologic deficits. headaches, fever, difficulties in speech, gait, & vision

immunoglobulins

-all antibodies that we create are immunoglobulins -found in blood and other body fluids -produced by B lymphocytes -blood test is used to quantitate each one in order to diagnose patients -too many indicated an allergy or over active immune system -not enough indicates risk for infection GAMED

cardio myopathy

-heart muscle disease process of -a thickening of heart muscles which obstructs the heart's normal ability to pump blood -infections, congestive heart failure, fatigue, weakness -leads to heart failure or death

Vaccines important supporting immune responses of older adults

-influenza -pneumococcal once when age 65 -herpes zoster once when age 60 -tetanus, diphtheria, and pertussis booster every 10 yrs -hydration

Osteoarthritis Characteristics

-over 60 and degenerative -non systemic -affects the hips, knees, big toes, base of thumbs, distal part of finger -worsens with activity **improves with rest** -can cause deformities such as bow legs -pain can progress to debilitating -decreased range of motion -chronic pain, stiffness, and tenderness

Immunity

-protection from illness or disease -physiologic defense mechanism -frontline of immune system is intact skin/mucous membranes/tonsils/saliva

Aldosterone

-released from adrenal cortex when sodium levels are low -holds onto sodium, which then holds onto water -part of the renin-angiotensin system -increases BP

Malignant Hyperthermia S/S

-tachycardia, arrhythmia -hypo/hypertension -skin mottling and cyanosis -soda colored urine (late sign) -rise in end tidal carbon dioxide -elevated temp (late sign)

General Innate (Natural) Immunity

-the nonspecific 1st line of defense against foreign pathogens or injury that evolves from birth (congenital/inherent) -continuously monitor their microenvironment for signs of distress -no memory -immediate Barriers: skin, mucous, hairs, stomach acid, saliva -the mucous traps and immobilizes foreign microbes -innate lacks specific response to a specific invader

What is microbiology?

-the study of living microorganisms that cannot be seen with the naked eye but can be seen using a microscope

Emergency Care of the Patient With Surgical Wound Evisceration

1. Contact surgeon immediately or Rapid Response Team to bring any needed supplies into the patient's room. 2. Provide reassurance and support to ease the patient's anxiety. If possible, stay with the patient and instruct him or her to remain in bed. 3. Using sterile technique, unfold a sterile towel to create a sterile field. 4. Open an irrigation set and place the basin and syringe on the sterile field. 5. Open several large abdominal dressings and place them on the sterile field. 6. Put on the sterile gloves and place one or two of the large abdominal dressings into the basin to saturate them with warm saline solution. 7. Place the moistened dressings over the exposed viscera. Then place a sterile, waterproof drape over the dressings to prevent the sheets from getting wet. 8. If saline is not immediately available, cover the wound with gauze and moisten with sterile saline when available. 9. Do not attempt to reinsert the protruding organ or viscera. 10. Assess for manifestations of shock and document vital signs. 11. Place the patient in a supine position with the hips and knees bent. 12. Raise the head of the bed 15 to 20 degrees. 13. Continue assessing the patient, including vital signs assessment every 5 to 10 minutes until the surgeon arrives. 14. Keep dressings continuously moist by adding warmed sterile saline to the dressing as often as necessary. Do not let the dressing become dry. 15. When the surgeon arrives, report finding and interventions. 16. Document the incident, the activity in which the patient was engaged at the time of the incident, assessment, and interventions taken. 17. If necessary, prepare the patient for emergency surgery; start an IV infusion as ordered. 18. Don't allow the patient to have anything by mouth to decrease the risk of aspiration if surgery is planned.

The priority collaborative problems for patients with chronic obstructive pulmonary disease (COPD) include:

1. Decreased GAS EXCHANGE due to alveolar-capillary membrane changes, reduced airway size, ventilatory muscle fatigue, excessive mucus production, airway obstruction, diaphragm flattening, fatigue, and decreased energy 2. Weight loss due to dyspnea, excessive secretions, anorexia, and fatigue 3. Anxiety due to a change in health status, and situational crisis 4. Decreased endurance due to fatigue, dyspnea, and an imbalance between oxygen supply and demand 5. Potential for pneumonia or other respiratory infections due to presence of thick secretions and the immunosuppressive effects of some drugs

The priority collaborative problems for patients with pneumonia include

1. Decreased GAS EXCHANGE due to decreased diffusion at the alveolar-capillary membrane 2. Potential for airway obstruction due to excessive pulmonary secretions, fatigue, muscle weakness 3. Potential for sepsis due to the presence of microorganisms in a very vascular area and decreased IMMUNITY. 4. Potential for pulmonary empyema due to spread of infectious organisms from the lung into the pleural space.

The priority collaborative problems for patients requiring tracheostomy include:

1. Decreased GAS EXCHANGE due to weak chest muscles, obstruction, or other physical problems that interfere with ventilation and diffusion of gases 2. Inadequate communication due to tracheostomy or intubation 3. Potential for weight loss due to inadequate nutrition from presence of endotracheal tube 4. Potential for infection due to invasive procedures or problems with the normal protective mechanisms of the respiratory tract 5. Potential for loss of tracheal TISSUE INTEGRITY due to pressure and trauma from tracheostomy tubes Interventions: Responding

The priority collaborative problems for patients with tuberculosis include:

1. Potential for airway obstruction due to thick secretions and weak cough effort 2. Potential for development of drug-resistant disease and spread of infection due to inadequate adherence to therapy regimen 3. Anxiety due to diagnosis 4. Weight loss due to inadequate intake and nausea from therapy regimen 5. Fatigue due to lengthy illness, poor GAS EXCHANGE, and increased energy demands

The priority collaborative problems for patients in the immediate postoperative period are:

1. Potential for decreased GAS EXCHANGE due to the effects of anesthesia, pain, opioid analgesics, and immobility 2. Potential for infection and delayed healing due to wound location, decreased mobility, drains and drainage, and tubes 3. Acute pain due to the surgical incision, positioning during surgery, and endotracheal tube (ET) irritation 4. Potential for decreased peristalsis due to surgical manipulation, opioid use, and fluid and electrolyte imbalances

Malignant Hyperthermia Treatment

1. Stop Anesthetics and Succinylcholine 2. Oxygen 3. Dantrolene Sodium (reversal agent) 4. Cool the Body 5. Blood gases, blood work 6. Close monitoring chart 15-1 pg. 260

Cell Mediated Immunity Process

1. The B cell finds an antigen which matches its receptors 2. It waits until it is activated by a helper T cell 3. Then the B cell divides to produce plasma and memory cells 4. Plasma cells produce antibodies that attach to the current type of invader 5. Eater cells prefer intruders marked with antibodies, and eat loads of them 6. If the same intruder invades again, memory cells help the immune system to activate much faster

Tiers of Ventilator-Associated Events

1. Ventilator-Associated Condition (VAC) Patient develops hypoxemia for a sustained period of more than 2 days, regardless of its etiology. 2. Infection-Related Ventilator-Associated Complication (IVAC) Hypoxemia develops in the setting of generalized infection or inflammation, and antibiotics are instituted for a minimum of 4 days. 3. Ventilator-Associated Pneumonia (VAP) There is additional laboratory evidence of white blood cells or Gram stain of material from a respiratory secretion specimen of acceptable quality and/or presence of respiratory pathogens on quantitative cultures from patients with IVAC.

Acute Respiratory Failure Assessment

1. level of consciousness (first signs: restlessness, anxiety, confusion) 2. distress with labored, irregular breathing 3. chest wall retractions 4. tachypnea leading to increased pH (alkalosis) 5. dyspnea 6. crackles/wheezes 7. unable to lie flat 8. increased sputum, cough, wet lung sounds 9. cyanosis (late sign) 10. decreased blood pressure 11. tachycardia 12. anxiety-fear of suffocation and lack of control

Respiratory Acidosis Interventions

1.Monitor for signs of respiratory distress. 2.Administer oxygen as prescribed. 3.Place the client in a semi-Fowler's position, unless contraindicated. 4.Encourage and assist the client to turn, cough, and deep-breathe. 5.Prepare to administer respiratory treatments as prescribed. 6.Encourage hydration to thin secretions, unless excess fluid intake is contraindicated. 7.Suction the client's airway, if necessary and if not contraindicated. 8.Reduce restlessness by improving ventilation rather than by administering tranquilizers, sedatives, or opioids because these medications further depress respirations.

Convalescent stage

patient responds to infection and symptoms decline return to full health

Methods of Transmission

contact- direct or indirect droplet airborne vector- insects/animals environment- food/water contamination

Calcium Functions

9.0-10.5 Bone and dental health, muscle and nerve function, blood clotting, cardiac rhythm. Helps stabilize cell membrane and keeps it calm by controlling what passes through

Hyponatremia (low sodium)

<135 Causes are vomiting, diarrhea, adrenal aldosterone, diuretics, water intoxication. Problems are decreased cell membrane excitability and causes cells to swell

Hypocalemia

<9.0 Causes are vitamin D deficiency, thyroid problems, GI issues, decreased Magnesium, increased phosphorus increased cell membrane excitability

Hypernatremia

>145 Increased cell membrane excitability Causes: too much broth, excessive sports drinks, sweating more water than sodium, vomiting, diarrhea, diuretics, hypertonic solutions, tube feedings, body system failure (renal), hyperaldosteronism, not enough water intake cells may shrink, increased BP

Hypermagnesemia

>2.6 Causes are increased calcium, decreased phosphorus, renal disease, antacids Decreased cell membrane excitability.--- everything is calm

Hypertonic Solutions

>300 mOsm/L D5 1/2, D5NS, 3%NS

Hyperkalemia

>5.0 Causes: over supplemented, renal failure, severe trauma, burns, cell lysis, acidosis increased cell membrane excitability

Tracheostomy Tubes

A cuffed tube is used for patients receiving mechanical ventilation. Always deflate the cuff before capping the tube with the decannulation cap; otherwise the patient has no airway. For tubes with a reusable inner cannula, inspect, suction, and clean the inner cannula. During the first 24 hours after surgery, perform cannula care as often as needed, perhaps hourly. Thereafter care is determined by the patient's needs and agency policy. In planning for self-care, teach the patient to remove the inner cannula and check for cleanliness. Instruct him or her about suctioning and tracheostomy cleaning. Because breathing and swallowing move the tube, even a cuffed tube does not protect against aspiration. Having a cuffed tube inflated may give a false sense of security that aspiration cannot occur during feeding or mouth care. In addition, the pilot balloon does not reflect whether the correct amount of air is present in the cuff. A fenestrated tube functions in many different ways. When the inner cannula is in place, the fenestration is closed, and this tube works like a double-lumen tube. With the inner cannula removed and the plug or stopper locked in place, air can pass through the fenestration, around the tube, and up through the natural airway so the patient can cough and speak. If the patient has trouble with these actions, he or she should be evaluated for proper tube placement, patency, size, and fenestration. Do not cap the tube until the problem is identified and corrected. A fenestrated tube may or may not have a cuff. With a cuff, some air flows through the natural airway when the patient is not being mechanically ventilated.

Malignant hyperthermia

A hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs.

Specific Immunity

Adaptive and Acquired -develop over lifetime -lymphocytes 20 to 40% (T cells, B cells, NK cells) EXPOSURE: vaccine, infection/disease, antibodies from another person uses a memory to respond; strategic and slower to respond than innate

Warfarin Therapy

According to the National Patient Safety Goals, therapeutic levels of warfarin must be monitored by measuring the international normalized ratio (INR) at frequent intervals. Because prothrombin times are often inconsistent and misleading, the INR was developed. Most laboratories report both results. Most patients receiving warfarin should have an INR between 1.5 and 2.0 to prevent future DVT and to minimize the risk for stroke or hemorrhage. For patients taking warfarin, assess for any bleeding, such as hematuria or blood in the stool. Ensure that vitamin K, the antidote for warfarin, is available in case of excessive bleeding (see Chart 36-7). Report any bleeding to the health care provider and document in the patient's health record. Teach patients to avoid foods with high concentrations of vitamin K, especially dark green leafy vegetables. These foods interfere with the action of warfarin, which is a vitamin K synthesis inhibitor.

acute respiratory distress syndrome (ARDS)

Acute respiratory distress syndrome (ARDS) is acute respiratory failure with these features: • Hypoxemia that persists even when 100% oxygen is given (refractory hypoxemia, a cardinal feature) • Decreased pulmonary compliance • Dyspnea • Noncardiac-associated bilateral pulmonary edema • Dense pulmonary infiltrates on x-ray (ground-glass appearance)

Hypersensitivity & Testing

Administered by patch, skin prick (scratch test), or intradermal -antihistimines, TCAs and heartburn meds interfere with testing -IgE would be elevated -patch test is used for latex, medication, dye, nickel, etc -skin prick can expose 30 substances and gives immediate response- food allergies can be difficult to detect; most reliable for airborne allergies -intradermal used for penicillin or insect venom *Have a crash cart*

Selected Factors That Increase the Risk for Surgical Complications

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

Focused Assessment 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 which setting and method of delivery? • What is the pulse oximetry reading? Cardiovascular Status • Are these values within the patient's baseline range? • Are peripheral pulses palpable? • What is the rate and rhythm of the heartbeat? • Are these values significantly different from when the patient was in the postanesthesia care unit (PACU)? 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 • Is the value significantly different from baseline and when the patient was in the PACU? Intravenous Fluids • Which type of solution is infusing and with which additives? • How much solution was remaining on arrival? • How much solution was 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?

Artificial Airway: Oral

An oral airway pulls the tongue forward and holds it down to prevent obstruction. If the patient had oral surgery or has clenched teeth, a large tongue, or upper airway obstruction, insert a nasal airway (nasal trumpet) to keep the airway open. A manual resuscitation bag and emergency equipment for intubation or tracheostomy should remain readily available in the PACU area. For patients whose only airway is a tracheostomy or laryngectomy stoma, alert other staff members by posting signs in the room and notes on the chart.

Aneurysm Assessment

Assess patients with a known or suspected abdominal aortic aneurysm (AAA) for abdominal, flank, or back pain. Pain is usually described as steady with a gnawing quality, unaffected by movement, and lasting for hours or days. A pulsation in the upper abdomen slightly to the left of the midline between the xiphoid process and the umbilicus may be present. A detectable aneurysm is at least 5 cm in diameter. Auscultate for a bruit over the mass, but avoid palpating the mass because it may be tender and there is risk for rupture! If expansion and impending rupture of an AAA are suspected, assess for severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs.

Respiratory Changes Associated With Aging: Chest Wall

Anteroposterior diameter increases. Thorax becomes shorter. Progressive kyphoscoliosis occurs. Chest wall compliance (elasticity) decreases. Mobility of chest wall may decrease. Interventions: Discuss the normal changes of aging. Patients may be anxious because they must work harder to breathe. Discuss the need for increased rest periods during exercise. Older patients have less tolerance for exercise.

VTE Drug Therapy

Anticoagulants are the drugs of choice for actual DVT and for patients at risk for DVT. However, these drugs are known to cause medical complications and even death. Therefore The Joint Commission's National Patient Safety Goals (NPSGs) include elements of performance to reduce the likelihood of patient harm associated with the use of anticoagulant therapy. The conventional treatment has been IV unfractionated heparin followed by oral anticoagulation with warfarin (Coumadin). However, unfractionated heparin can be problematic because each patient's response to the drug is unpredictable and hospital admission is usually required for laboratory monitoring and dose adjustments. The use of low-molecular-weight heparin (LMWH) and the development of novel oral anticoagulants (NOACs, also referred to as direct oral anticoagulants [DOACs]) has changed the management of both DVT and PE.

Renal disease and hypertension

Any damage to the kidney can cause high blood pressure. ALSO, high blood pressure can cause renal disease. Pay attention to BUN, creatine, GFR. Remember: Na+ and water retention causes increased BP

Collecting Urine Specimen from Catheter

Apply gloves • Cleanse needleless port on urinary cath • Collect 1-5mL of urine using needless safety syringe • Fill sterile specimen tube and place on clean towel in Pt's bathroom • Secure top of transfer container • Label container in front of client • Place in biohazard bag with label attached • Remove gloves • Perform hand hygiene

Focused Assessment The Preoperative Patient

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 further evaluation before proceeding with the surgical plans, including: • Change in mental status • Vomiting • Rash • Recent administration of an anticoagulant drug Assess and determine functionality of any implantable cardiovascular devices: • Pacemaker • Implantable cardioverter defibrillators (ICDs) Evaluate patient and family past medical history that may need further evaluation: • History of ischemic heart disease and interventions • History of cerebrovascular disease and interventions

COPD History Assessment

Ask about risk factors such as age, gender, and occupational history. COPD is seen more often in older men. Some types of emphysema occur in families, especially those with alpha1-antitrypsin (AAT) deficiency. Obtain a thorough smoking history, because tobacco use is a major risk factor. Ask about the length of time the patient has smoked and the number of packs smoked daily. Use these data to determine the pack-year smoking history. Ask the patient to describe the breathing problems and assess whether he or she has any difficulty breathing while talking. Does he or she speak in complete sentences, or is it necessary to take a breath between every one or two words? Ask about the presence, duration, or worsening of wheezing, coughing, and shortness of breath. Determine which activities trigger these problems. Assess any cough, and ask whether sputum is clear or colored and how much is produced each day. Ask about the time of day when sputum production is greatest. Smokers often have a productive cough when they get up in the morning; nonsmokers generally do not. Ask the patient to compare the activity level and shortness of breath now with those of a month ago and a year ago. Ask about any difficulty with eating and sleeping. Many patients sleep in a semi-sitting position because breathlessness is worse when lying down (orthopnea). Ask about any difficulty with ADLs or sexual activity. Document this assessment to personalize the intervention plan. Weigh the patient and compare this weight with previous weights. Unplanned weight loss is likely when COPD severity increases, because the work of breathing increases metabolic needs. Dyspnea and mucus production often result in poor food intake and inadequate nutrition. Ask the patient to recall a typical day's meals and fluid intake. When heart failure is present with COPD, general edema with weight gain may occur.

Nursing Implications: Pyrazinamide (PZA) Can effectively kill organisms residing within the very acidic environment of macrophages (which is where the tuberculosis bacillus sequesters) Available only in combination with other anti-TB drugs

Ask whether the patient has ever had gout because the drug increases uric acid formation and will make gout worse. Instruct patients to drink at least 8 ounces of water when taking this tablet and to increase fluid intake to prevent uric acid from precipitating, making gout or kidney problems worse. Teach the patient to wear protective clothing, a hat, and sunscreen when going outdoors in the sunlight because the drug causes photosensitivity and greatly increases the risk for sunburn. Remind the patient to avoid drinking alcoholic beverages while on this drug because the liver-damaging effects of this drug are potentiated by drinking alcohol. Tell 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, which are signs and symptoms of liver toxicity or failure.

Emergency Care of Patients With Hypertensive Urgency or Crisis

Assess • Severe headache • Extremely high blood pressure (BP) • Dizziness • Blurred vision • Shortness of breath • Epistaxis (nosebleed) • Severe anxiety Intervene • Place patient in a semi-Fowler's position. • Administer oxygen. • Start IV of 0.9% normal saline (NS) solution slowly to prevent fluid overload (which would increase BP). • Administer IV beta blocker or nicardipine (Cardene IV) or other infusion drug as prescribed; when stable, switch to oral antihypertensive drug. • Monitor BP every 5 to 15 minutes until the diastolic pressure is below 90 and not less than 75; then monitor BP every 30 minutes to ensure that BP is not lowered too quickly. • Observe for neurologic or cardiovascular complications, such as seizures; numbness, weakness, or tingling of extremities; dysrhythmias; or chest pain (possible indicators of target organ damage).

Rhinosinusitis Assessment and Treatment

Assess for signs and symptoms of rhinosinusitis. Common symptoms include pain over the cheek radiating to the teeth, tenderness to percussion over the sinuses, referred pain to the temple or back of the head, and general facial pain that is worse when bending forward. Additional symptoms in bacterial infection include purulent nasal drainage with postnasal drip, sore throat, fever, erythema, swelling, fatigue, dental pain, and ear pressure. Management focuses on symptom relief and patient education. Teach him or her about correct use of the drug therapy prescribed. Drug therapy commonly includes decongestants and intranasal steroid spray. Antihistamines, leukotriene inhibitors, and mast cell stabilizers block or reduce the amount of chemical mediators in nasal and sinus tissues and prevent local edema and itching. Decongestants constrict blood vessels and decrease edema. Antipyretics are given if fever is present, and analgesics may be given for pain.

Diuretics Nursing Implications Common examples of diuretics: • Potassium-sparing: Spironolactone (Aldactone) • Loop: Furosemide (Lasix); bumetanide (Bumex, Burinex ) • Thiazide: Hydrochlorothiazide (Microzide, Urozide ); chlorothiazide (Diuril)

Assess for weakness, dizziness, or a new onset of confusion because these drugs can cause hypovolemia and dehydration. Teach older adults to rise slowly because the medication can cause orthostatic hypotension associated with diuresis. For potassium-sparing agents: • Teach the patient to decrease intake of foods that are high in potassium and have follow-up laboratory tests for electrolyte levels because these agents cause retention of K+ in the body. • Teach the patient to report weakness and irregular pulse to the primary health care provider because these symptoms may indicate hyperkalemia. For loop and thiazide agents: • Teach the patient to eat foods high in K+ and to have follow-up laboratory tests to monitor electrolyte levels because these agents cause K+ and Mg2+excretion. • Use with caution in patients with diabetes because glucose control can be affected. • Use with caution in patients with gout because uric acid retention can occur.

Beta Blockers Nursing Implications Common examples of beta blockers: • Atenolol (Tenormin, Apo-Atenol) • Metoprolol (Lopressor, Toprol XL, Betaloc)

Assess heart rate (HR) and blood pressure (BP) before administration because beta blockers cause a decrease in HR and cardiac output and suppress renin activity. • Do not administer if HR is <50-60 beats/min. • Hold for systolic <90-100 mm HG and contact the health care provider. • Monitor for orthostatic hypotension because this is a common adverse effect that can contribute to falls and confusion, especially in older adults. Use with caution in patients with diabetes because glucose production may be affected. Teach the patient that these agents can cause fatigue, depression, and sexual dysfunction. These adverse effects should be reported to the primary health care provider.

methemoglobinemia

Assess patients who receive a benzocaine topical anesthetic to the oropharynx to recognize indications of methemoglobinemia. These include cyanosis that is unresponsive to oxygen therapy and chocolate-brown-colored blood. If either of these symptoms is present, respond by notifying the Rapid Response Team.

Home Care Assessment The Patient With Chronic Obstructive Pulmonary Disease

Assess respiratory status and adequacy of GAS EXCHANGE. • Measure rate, depth, and rhythm of respirations. • Examine mucous membranes and nail beds for evidence of hypoxia. • Determine use of accessory muscles. • Examine chest and abdomen for paradoxical breathing. • Count number of words patient can speak between breaths. • Determine need and use of supplemental oxygen. (How many liters per minute is the patient using?) • Determine level of consciousness and presence/absence of confusion. • Auscultate lungs for abnormal breath sounds. • Measure oxygen saturation by pulse oximetry. • Determine sputum production, color, and amount. • Ask about activity level. • Observe general hygiene. • Measure body temperature. Assess cardiac status for adequate PERFUSION. • Measure rate, quality, and rhythm of pulse. • Check dependent areas for edema. • Check neck veins for distention with the patient in a sitting position. • Measure capillary refill. Assess nutritional status. • Check weight maintenance, loss, or gain. • Determine food and fluid intake. • Determine use of nutritional supplements. • Observe general condition of the skin. Assess patient's and caregiver's adherence and understanding of illness and treatment, including: • Correct use of supplemental oxygen • Correct use of inhalers • Drug schedule and side effects • Symptoms to report to the primary health care provider indicating the need for acute care • Increasing severity of resting dyspnea • Increasing severity of usual symptoms • Development of new symptoms associated with poor GAS EXCHANGE • Respiratory infection • Failure to obtain the usual degree of relief with prescribed therapies • Unusual change in condition • Use of pursed-lip and diaphragmatic breathing techniques • Scheduling of rest periods and priority activities • Participation in rehabilitation activities

Home Care Assessment Patients After Laryngectomy

Assess respiratory status and effectiveness of GAS EXCHANGE: • Observe rate and depth of respiration. • Auscultate lungs. • Check patency of airway. • Examine the tracheostomy drainage for amount, color, and character. • Examine nail beds and mucous membranes for evidence of cyanosis. • Obtain a pulse oximetry reading. Assess condition of wound and TISSUE INTEGRITY: • Remove dressings (noting condition of dressings). • Cleanse the wound. • Compare with previous notations of wound condition: • Presence, amount, and nature of exudate • Presence/absence of cellulitis • Presence/absence of odor Assess patient's psychosocial status: • Ask the patient about passing the time, visitors, and trips outside the house. • Observe whether the patient communicates responses directly or whether a family member speaks for him or her. • Observe patient and family member interactions. • Determine which method of communication the patient has selected and observe the patient's skill with it. • Observe whether the patient is wearing pajamas or is dressed in street clothes. • Take the patient's temperature at each home care visit. Assess the patient's understanding of illness and adherence to treatment: • Manifestations to report to the health care provider • Medication plan (correct timing and dose) • Ambulation or positioning schedule • Dressing changes/skin care • Diet modifications (24-hour diet recall) • Skill in tracheostomy or dressing care Assess patient's NUTRITION status: • Change in muscle mass • Lackluster nails/sparse hair • Recent weight loss greater than 10% of usual weight • Impaired oral intake • Difficulty swallowing • Generalized edema

The Patient After Pulmonary Embolism

Assess respiratory status: • Observe rate and depth of ventilation. • Auscultate lungs. • Examine nail beds and mucous membranes for evidence of cyanosis, indicating reduced GAS EXCHANGE. • Take a pulse oximetry reading. • Ask the patient if chest pain or shortness of breath is experienced in any position. • Ask the patient about the presence of sputum and its color and character. Assess cardiovascular status: • Take vital signs, including apical pulse, pulse pressure; assess for presence or absence of orthostatic hypotension and quality and rhythm of peripheral pulses. • Note presence or absence of peripheral edema. • Examine hand vein filling in the dependent position. • Examine neck vein filling in the recumbent and sitting positions. Assess lower extremities for deep vein thrombosis: • Examine lower legs and compare with each other for: • General edema • Calf swelling • Surface temperature • Presence of red streaks or cordlike, palpable structure • Measure calf circumference. Assess for evidence of bleeding: • Examine the mouth and gums for oozing or frank bleeding. • Examine all skin areas, especially old puncture sites and wounds, for bleeding, bruising, or petechiae. • If the patient voids during the visit, test the urine for occult blood. Assess cognition and mental status: • Check level of consciousness. • Check orientation to time, place, and person. • Can the patient accurately read a seven-word sentence containing no words with more than three syllables? Assess the patient's understanding of illness and adherence to treatment: • Symptoms to report to health care provider • Drug therapy plan (correct timing and dose) • Bleeding Precautions • Prevention of venous thromboembolism

Home Care Assessment The Patient With Peripheral Vascular Disease

Assess tissue perfusion to affected extremity(ies), including: • Distal circulation, sensation, and motion • Presence of pain, pallor, paresthesias, pulselessness, paralysis, poikilothermy (coolness) • Ankle-brachial index Assess adherence to therapeutic regimen, including: • Following foot care instructions • Quitting smoking • Maintaining dietary restrictions • Participating in exercise regimen • Avoiding exposure to cold and constrictive clothing Assess ability to manage wound care and prevent further injury, including: • Use of compression stockings or compression pumps as directed • Use of various dressing materials • Signs and symptoms to report to nurse Assess coping ability of patient and family members. Assess home environment, including: • Safety hazards, especially related to falls

Respiratory Health Promotion

Assessing exposure to inhalation irritants should be part of any health assessment within the demographic history. Include the patient's current and past geographic living area, home conditions, occupation, and hobbies. Areas with high levels of air pollution contribute to respiratory problems. Exposure to dust, particles, chemicals, gases. or toxic fumes can occur in the workplace, making work history information important. Ask about dates of employment and a brief job description. Exposure to industrial dusts of any type or to chemical fumes may cause breathing disorders. Bakers, coalminers, stone masons, cotton handlers, woodworkers, welders, potters, plastic and rubber manufacturers, printers, farm workers, those working in grain elevators or flour mills, and steel foundry workers are at risk for work-related breathing problems. Ask about the type of heat used at home (e.g., gas heater, wood-burning stove, fireplace, kerosene heater). Determine exposure to irritants (e.g., fumes, chemicals, animals, birds, air pollutants). Ask about hobbies such as painting, ceramics, model airplanes, refinishing furniture, or woodworking, which may expose the patient to harmful chemicals.

Assessment of the Pharynx, Trachea, and Larynx

Assessment of the pharynx begins with inspection of the mouth. To examine the posterior pharynx, use a tongue depressor to press down one side of the tongue at a time (to avoid stimulating the gag reflex). As the patient says "ah," observe the rise and fall of the soft palate and inspect for color and symmetry, drainage, edema or ulceration, and enlarged tonsils. Inspect the neck for symmetry, alignment, masses, swelling, bruises, and the use of accessory neck muscles in breathing. Palpate lymph nodes for size, shape, mobility with palpation, consistency, and tenderness. Gently palpate the trachea for position, mobility, tenderness, and masses. The trachea should be in the midline. Many lung disorders cause the trachea to deviate from the midline. Tension pneumothorax, large pleural effusion, mediastinal mass, and neck tumors push the trachea away from the affected area. Pneumonectomy, fibrosis, and atelectasis pull it toward the affected area.

Hypertensive Crisis

BP > 180/120 IV vasodilators Nitroprusside Nicardipine Labetalol Goal: Reduce BP by 25% in 2-6 hours Gradual reduction prevents cerebral ischemia,MI, renal failure

The Major 5 types of microorganisms

Bacteria Virus Fungi Protozoa Prions

Stage 4 (Danger)

Begins with depression of vital functions and ends with respiratory failure, cardiac arrest, and possible death. Respiratory muscles are paralyzed; apnea occurs. Pupils are fixed and dilated. Prepare for and assist in treatment of cardiac and/or pulmonary arrest. Document occurrence in the patient's chart. Teamwork and preparedness help decrease injuries and complications and promote the possibility of a desired outcome for the patient.

Stage 2 (Excitement, Delirium)

Begins with loss of consciousness and ends with relaxation, regular breathing, and loss of the eyelid reflex.Avoid auditory and physical stimuli.Sensory stimuli can contribute to the patient's response.Patient may have irregular breathing, increased muscle tone, and involuntary movement of the extremities.Protect the extremities.Safety measures help prevent injury.Laryngospasm or vomiting may occur.Assist the anesthesiologist or CRNA with suctioning as needed.Adequate suctioning of vomitus can prevent aspiration.Patient is susceptible to external stimuli.Stay with patient.Staying with the patient is emotionally supportive

Tracheostomy bleeding

Bleeding in small amounts from the tracheotomy incision is expected for the first few days, but constant oozing is abnormal. Wrap gauze around the tube and pack gauze gently into the wound to apply pressure to the bleeding sites. Bleeding can occur in the trachea itself or in the tissues surrounding the incision. If hemorrhage occurs, the site may need surgical exploration or ligation of blood vessels.

Respiratory Psychosocial Assessment

Breathing difficulty often induces anxiety. The patient may be anxious because of reduced oxygen to the brain or because the sensation of not getting enough air is frightening. The thought of having a serious problem, such as lung cancer, can also induce anxiety. Encourage the patient to express his or her feelings and fears about symptoms and their possible meaning. Assess those aspects of the patient's lifestyle that either can affect respiratory function or are affected by it. Some respiratory problems may become worse with stress. Ask about current life stresses and usual coping mechanisms. Chronic respiratory disease may cause changes in family roles or relationships, social isolation, financial problems, and unemployment or disability. Discuss coping mechanisms to assess the patient's reaction to these stressors and identify strengths.

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-secreting 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. The increased 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).

Anesthesia

Induced state of partial or total loss of sensation, occurring with or without loss of consciousness. -block nerve impulse transmission -suppress reflexes -muscle relaxation -achieve controlled level of unconsciousness

Capnometry and Capnography

Capnometry and capnography are methods that measure the amount of carbon dioxide present in exhaled air, which is an indirect measurement of arterial carbon dioxide levels. These noninvasive tests measure the partial pressure of end-tidal carbon dioxide (PEtCO2, also known as EtCO2) levels in both intubated patients and those breathing spontaneously. With capnometry, the exhaled air sample is tested with a sensor that changes the CO2 level into a color or number for analysis. With capnography, the CO2 level is graphed as a specific waveform along with a number. These methods provide information about CO2 production, pulmonary perfusion, alveolar ventilation, respiratory patterns, ventilator effectiveness, and possible rebreathing of exhaled air. Because capnography is a more sensitive indicator of gas exchange adequacy than pulse oximetry, it can be especially useful in early detection of respiratory depression

Ventilator Associated Events

Cardiac problems from mechanical ventilation include hypotension and fluid retention. Lung problems from mechanical ventilation include: • Barotrauma (damage to the lungs by positive pressure) • Volutrauma (damage to the lung by excess volume delivered to one lung over the other) • Atelectrauma (shear injury to alveoli from opening and closing) • Biotrauma (inflammatory response-mediated damage to alveoli) • Ventilator-associated lung injury/ventilator-induced lung injury (VALI/VILI) (damage from prolonged ventilation causing loss of surfactant, increased inflammation, fluid leakage, and noncardiac pulmonary edema) • Acid-base imbalance GI and nutrition problems result from the stress of mechanical ventilation. Stress ulcers occur in many patients receiving mechanical ventilation. Muscle deconditioning and weakness can occur because of immobility. Ventilator dependence is the inability to wean off the ventilator and can have both a physiologic and a psychological basis.

Obstructive sleep apnea interventions

Changes in sleeping position or weight loss may correct mild sleep apnea and improve GAS EXCHANGE. Position-fixing devices may prevent subluxation of the tongue and reduce obstruction. Severe OSA requires additional methods to prevent obstruction. A common method to prevent airway collapse is the use of noninvasive positive-pressure ventilation (NPPV) to hold open the upper airways. A nasal mask or full-facemask delivery system allows mechanical delivery of either bi-level positive airway pressure (BiPAP), autotitrating positive airway pressure (APAP), or nasal continuous positive airway pressure (CPAP). One drug has been approved to help manage the daytime sleepiness associated with OSA (modafinil [Attenace, Provigil]) and may help patients who have narcolepsy (uncontrolled daytime sleep) by promoting daytime wakefulness. This drug does not treat the cause of OSA. Sleep-inducing sedatives also are not considered first-line therapy. Surgical intervention may involve a simple adenoidectomy, uvulectomy, or remodeling of the entire posterior oropharynx (uvulopalatopharyngoplasty [UPP]). Both conventional and laser surgeries are used for this purpose. A tracheostomy may be needed for very severe sleep apnea that is not relieved by more moderate interventions.

Care Issues for the Patient With a Tracheostomy: Preventing Tissue Damage

Check the cuff pressure at least once during each shift using either a pressure cuff inflator or the minimal leak technique. When using the minimal leak technique to ensure adequate cuff pressure and reduce the risk for pressure injury, a pressure cuff inflator is not used. Instead, after completing tracheostomy care and suctioning the airway above the cuff, attach a 10-mL Luer-Lok syringe to the valve in the pilot balloon. Place a stethoscope on the side of the patient's neck near the tracheostomy tube and slowly deflate the cuff with the syringe while listening for a loud, gurgling air rush as the seal is broken and air bypasses the tracheostomy tube on inhalation. Then while re-injecting the air in the syringe, continue to listen for air passing the cuff. When air is no longer heard passing the cuff, the airway is sealed. At this point, remove 1 mL of air from the cuff. This ensures that the airway is sealed sufficiently to allow adequate ventilation and keep the tube fitting just loose enough to prevent tracheal injury. Although a high cuff pressure alone can injure tracheal TISSUE INTEGRITY, other factors contribute to the risk for damage (Makic et al., 2013). The patient who is malnourished, dehydrated, hypoxic, older, or receiving corticosteroids is at risk for greater tissue damage. Tube friction and movement damage the mucosa and lead to tracheal stenosis. Reduce local airway damage by maintaining proper cuff pressures, stabilizing the tube, suctioning only when needed, and preventing malnutrition, dehydration, and hypoxia.

Lung Cancer Non-Surgical Management

Chemotherapy is often the treatment of choice for lung cancers, especially small cell lung cancer (SCLC). It may be used alone or as adjuvant therapy in combination with surgery for non-small cell lung cancer (NSCLC). The combination of drugs used depends on tumor response and the overall health of the patient. Immunosuppression with neutropenia, which greatly increases the risk for infection, is the major dose-limiting side effect of chemotherapy for lung cancer. It can be managed by the use of growth factors to stimulate bone marrow production of immune system cells. Teach the patient and family about precautions to take to reduce the patient's risk for infection. Targeted therapy is common in the treatment of non-small cell lung cancer (NSCLC). These agents take advantage of one or more differences in cancer cell growth or metabolism that is either not present or only slightly present in normal cells. Radiation therapy can be an effective treatment for locally advanced lung cancers confined to the chest. Best results are seen when radiation is used in addition to surgery or chemotherapy. Photodynamic therapy (PDT) may be used to remove small bronchial tumors when they are accessible by bronchoscopy. The patient is first injected with an agent that sensitizes cells to light.

Respiratory Imaging Assessment

Chest x-rays are used to assess lung pathology such as with pneumonia, atelectasis, pneumothorax, and tumor. They also can detect pleural fluid and the placement of an endotracheal tube or other invasive catheters. A computer-enhanced image can be adjusted to emphasize a specific area. However, these images have limitations and may appear normal, even when severe chronic bronchitis, asthma, or emphysema is present. Sinus and facial x-rays are used to assess fluid levels in the sinus cavities to assist in the diagnosis of acute or chronic sinusitis. Computed tomography (CT) assesses soft tissues with consecutive cross-sectional views of the entire chest. This type of imaging can verify the identity of a suspicious lesion or clot. CT scans may require a contrast agent injected IV to enhance the visibility of tumors, blood vessels, and heart chambers. Your role is to provide information to the patient and determine whether he or she has any sensitivity to the contrast material.

Lung Cancer Pulmonary Assessment

Chills, fever, and cough may be related to pneumonitis or bronchitis that occurs with obstruction. Assess sputum quantity and character. Blood-tinged sputum may occur with bleeding from a tumor. Hemoptysis is a later finding in the course of the disease. If infection or necrosis is present, sputum may be purulent and copious. Breathing may be labored or painful. Obstructive breathing may occur as prolonged exhalation alternating with periods of shallow breathing. Rapid, shallow breathing occurs with pleuritic chest pain and an elevated diaphragm. Look for and document abnormal retractions, the use of accessory muscles, flared nares, stridor, and asymmetric diaphragmatic movement on inspiration. Dyspnea and wheezing may be present with airway obstruction. Ask about dyspnea severity at rest, with activity, and in the supine position. Assess how much the dyspnea interferes with the patient's participation in ADLs, work, recreational activities, and family responsibilities. Ask him or her to compare participation in activities during the past week with that of a month ago and a year ago. Areas of tenderness or masses may be felt when palpating the chest wall. Increased vibrations felt on the chest wall (fremitus) indicate areas of the lung where air spaces are replaced with tumor or fluid. Fremitus is decreased or absent when the bronchus is obstructed. The trachea may be displaced from midline if a mass is present in the area. Lung areas with masses sound dull or flat rather than hollow or resonant on chest percussion. Breath sounds may change with the presence of a tumor. Wheezes indicate partial obstruction of airflow in passages narrowed by tumors. Decreased or absent breath sounds indicate complete obstruction of an airway by a tumor or fluid. Increased loudness or sound intensity of the voice while listening to breath sounds indicates increased density of lung tissue from tumor compression. A pleural friction rub may be heard when inflammation is present.

Prophylaxis and Treatment of Inhalation Anthrax

Ciprofloxacin (Cipro) 500 mg orally twice daily- Ciprofloxacin (Cipro IV) 400 mg IV every 12 hr Doxycycline (Vibramycin) 100 mg orally twice daily- Doxycycline (Doxy 100) 100 mg IV every 12 hour (if organism is proven susceptible to penicillin) Plus one or two of the following secondary agents (parenteral form (IV); dosage based on patient's weight and age):Amoxicillin (Amoxil, Trimox) 500 mg orally every 8 hr or 875 mg orally twice daily- Rifampin (RIF) Clindamycin (Cleocin) Vancomycin (Vancocin, Vancoled) Prophylaxis must continue for 60 days (or longer if exposure was heavy).Treatment with IV drugs continues for at least 7 days. When the response is good and the patient improves, IV drugs are changed to oral agents and continued for at least 60 days.

Correlation of Dyspnea Classification With Performance of ADLs

Class I: No significant restrictions in normal activity. Employable. Dyspnea occurs only on more-than-normal or strenuous exertion. 4: No breathlessness, normal. Class II: Independent in essential ADLs but restricted in some other activities. Dyspneic on climbing stairs or on walking on an incline but not on level walking. Employable only for sedentary job or under special circumstances. 3: Satisfactory, mild breathlessness. Complete performance is possible without pause or assistance but not entirely normal. Class III: Dyspnea commonly occurs during usual activities such as showering or dressing, but the patient can manage without assistance from others. Not dyspneic at rest; can walk for more than a city block at own pace but cannot keep up with others of own age. May stop to catch breath partway up a flight of stairs. Is not likely to be employed .2: Fair, moderate breathlessness. Must stop during activity. Complete performance is possible without assistance, but performance may be too debilitating or time consuming. Class IV: Dyspnea produces dependence on help in some essential ADLs such as dressing and bathing. Not usually dyspneic at rest. Dyspneic on minimal exertion; must pause on climbing one flight, walking more than 100 yards, or dressing. Often restricted to home if lives alone. Has minimal or no activities outside of home. 1: Poor, marked breathlessness. Incomplete performance; assistance is necessary. Class V: Entirely restricted to home and often limited to bed or chair. Dyspneic at rest. Dependent on help for most needs. 0: Performance not indicated or recommended; too difficult

Burger's Disease

Claudication in feet and lower extremities worse at night; causes ischemia and fibrosis of vessels in extremities with increased sensitivity to cold; ulcerations and gangrene on digits; cause unknown but is associated with smoking. Treatment: Vasodilating drugs, such as nifedipine (Procardia); management of ulceration and gangrene; chronic pain management modalitiesTeach patient about smoking cessation, avoiding cold by wearing gloves and warm clothes, managing stress, avoiding caffeine; teach patient taking nifedipine to avoid grapefruit and grapefruit juice to prevent severe adverse effects, including possible death; teach patients on vasodilators about side effects such as facial flushing, hypotension, headaches.

TB Drug Therapy

Combination drug therapy is the most effective method of treating TB and preventing transmission. Active TB is treated with a combination of drugs to which the organism is sensitive. Therapy continues until the disease is under control. Multiple-drug regimens destroy organisms as quickly as possible and reduce the emergence of drug-resistant organisms. First-line therapy uses isoniazid (INH, Nidrazid), rifampin (Rifadin), pyrazinamide, and ethambutol (Myambutol) for the first 8 weeks, which is called the initial phase of treatment. The continuation phase lasts another 18 weeks, and the patient takes INH and rifampin either daily or twice a week (CDC, 2015l). These drugs are now available in two- 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.

A patient with HIV that goes without treatment can die of an ___________ infection such as cancer

opportunist

Hazards and Complications of Oxygen Therapy

Combustion Oxygen-induced hypoventilation Hypercarbia—retention of CO2 CO2 narcosis—loss of sensitivity to high levels of CO2 Oxygen toxicity Absorption atelectasis—new onset of crackles/decreased breath sounds Drying of mucous membranes Infection Monitor the patient receiving high levels of oxygen closely to recognize indications of absorptive atelectasis (new onset of crackles and decreased breath sounds) every 1 to 2 hours when oxygen therapy is started and as often as needed thereafter. Assess the tubing system used for oxygen delivery to recognize buildup of condensation. Respond by draining condensation. To prevent bacterial contamination of the oxygen delivery system, never drain the fluid from the water trap back into the humidifier or nebulizer. Infection.

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 IMMUNITY • 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 reduced IMMUNITY (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])

COPD complications

Complications include hypoxemia, acidosis, respiratory infection, cardiac failure, dysrhythmias, and respiratory failure. Hypoxemia and acidosis occur because the patient with COPD has reduced gas exchange, leading to decreased oxygenation and increased carbon dioxide levels. These problems reduce cellular function. Respiratory infection risk increases because of the increased mucus and poor GAS EXCHANGE. Bacterial infections are common and make COPD symptoms worse by increasing inflammation and mucus production and inducing more bronchospasm. Airflow becomes even more limited, the work of breathing increases, and dyspnea results. Cardiac failure, especially cor pulmonale (right-sided heart failure caused by pulmonary disease), occurs with bronchitis or emphysema. Cardiac dysrhythmias are common in patients with COPD. They result from hypoxemia (from decreased oxygen to the heart muscle), other cardiac disease, drug effects, or acidosis.

Tracheomalacia

Constant pressure exerted by the cuff causes tracheal dilation and erosion of cartilage, leading to loss of tissue integrity. An increased amount of air is required in the cuff to maintain the seal. A larger tracheostomy tube is required to prevent an air leak at the stoma. Food particles are seen in tracheal secretions. The patient does not receive the set tidal volume on the ventilator. No special management is needed unless bleeding occurs. Use an uncuffed tube as soon as possible. Monitor cuff pressure and air volumes closely and detect changes.

Community Acquired Pneumonia (CAP)

Contracted outside a health care setting; acquired in the community Most common bacterial agents: Streptococcus pneumoniae, Haemophilus influenzae Most common viral agents: influenza, respiratory syncytial virus (RSV) Antibiotics are often empirical based on multiple patient and environmental factors Treatment length: minimum of 5 days Prompt initiation of antibiotics required; in ED setting, first dose given before patient leaves unit for inpatient bed or within 6 hours of presentation to the ED

Respiratory: Assessing Current Health Problems

Cough is a sign of lung disease. Ask the patient how long the cough has been present and whether it occurs at a specific time of day (e.g., on awakening in the morning) or in relation to any physical activity. Ask whether the cough produces sputum or is dry, tickling, or hacking. Sputum production is an important symptom associated with coughing. Check the color, consistency, odor, and amount of sputum. Describe the consistency of sputum as thin, thick, watery, or frothy. Smokers with chronic bronchitis have mucoid sputum. Excessive pink, frothy sputum is common with pulmonary edema. Bacterial pneumonia often produces rust-colored sputum, and a lung abscess may cause foul-smelling sputum. Hemoptysis (blood in the sputum) may be seen in patients with chronic bronchitis or lung cancer. Grossly bloody sputum may occur with tuberculosis, pulmonary infarction, lung cancer, or lung abscess. Ask the patient to quantify sputum by describing its volume in terms such as teaspoon, tablespoon, and cup. Normally the lungs can produce up to 90 mL of sputum per day. Chest pain can occur with other health problems in addition to with lung problems. A detailed description of chest pain helps distinguish its cause. Ask whether the pain is continuous or made worse by coughing, deep breathing, or swallowing. Cardiac pain is usually intense and "crushing" and may radiate to the arm, shoulder, or neck. Pulmonary pain varies, depending on the cause, and most often feels like something is "rubbing" inside. Pain may appear only on deep inhalation or be present at the end of inhalation and the end of exhalation. Pulmonary pain is not made worse by touching or pressing over the area. Dyspnea (difficulty in breathing or breathlessness) is a subjective perception and varies among patients (Baker et al., 2013). A patient's feeling of dyspnea may not be consistent with the severity of the problem. However, patients with chronic lung disease can reliably report dyspnea levels that accurately correspond to the severity of their disease (Croucher, 2014). Determine the type of onset (slow or abrupt), the duration, relieving factors (position changes, drug use, activity cessation), and whether wheezing or stridor occurs with dyspnea. Try to quantify dyspnea by asking whether this symptom interferes with ADLs and, if so, how severely. Ask about orthopnea, which is shortness of breath occurring when lying down and is relieved by sitting up. Assess for paroxysmal nocturnal dyspnea (PND), which awakens the patient from sleep with the feeling of an inability to breathe. PND also occurs while lying flat and is relieved by sitting up. It often occurs with chronic lung disease and left-sided heart failure.

Somatic Pain

Cutaneous or superficial: skin and subcutaneous tissues Well localized Sharp, throbbing Incisional pain, pain at insertion sites of tubes and drains, wound complications, orthopedic procedures, skeletal muscle spasms Bony metastases, osteoarthritis and rheumatoid arthritis, low back pain, peripheral vascular diseases Deep somatic: bone, muscle, blood vessels, connective tissues Dull, aching, cramping

Hypersensitivity ReactionsType II

Cytotoxic Reactions •Body makes autoantibodies directed at self cells. •Self cells are destroyed •Examples: hemolytic anemia, thrombocytopenic purpura, hemolytic transfusion reaction (wrong blood type), drug induced hemolytic anemia. Myasthenia gravis • Management: Stop drug or blood product / Plasmapheresis

Fluid Overload Planning

patient safety restore fluid balance provide supportive care until balance is restored prevention

Natriuretic peptide

Released by the heart when heart tissue is stretched. -ANP from the atria -BNP from the ventricles Decreased sodium reabsorption -inhibits aldosterone secretion Increased urine output -inhibits ADH secretion

Perioperative Respiratory Care

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. 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 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

Acidosis Lab Assessment

Metabolic Acidosis: low HCO3, low pH, high K+ Respiratory acidosis: high CO2, low pH, high K+

Corticosteroids

Disrupt production pathways of inflammatory mediators. The main purpose is to prevent an asthma attack caused by inflammation or allergies (controller drug).

HTN Drug Therapy

Diuretics- Decrease blood volume Calcium channel blockers- Vasodilation Angiotensin converting enzyme inhibitors (ACE inhibitors)- Prevents vasoconstriction, prevents sodium/water retention Angiotensin II receptor blockers (ARBs)- Prevents vasoconstriction, promote vasodilation Beta-adrenergic blockers (second line)- Decreases heart rate and cardiac contractility

Can you massage the patient's calves?

Do not massage the calves because of the risk for loosening a clot and causing a life-threatening pulmonary embolus.

Fractures of the Nose

Document any nasal problem, including deviation, malaligned nasal bridge, a change in nasal breathing, crackling of the skin (crepitus) on palpation, bruising, and pain. Blood or clear fluid (cerebrospinal fluid [CSF]) rarely drains from one or both nares as a result of a simple nasal fracture and, if present, indicates a serious injury (e.g., skull fracture). CSF can be differentiated from normal nasal secretions because CSF contains glucose that will test positive with a dipstick test for glucose. When CSF dries on a piece of filter paper, a yellow "halo" appears as a ring at the dried edge of the fluid. The primary health care provider performs a simple closed reduction (moving the bones by palpation to realign them) of the nasal fracture using local or general anesthesia within the first 24 hours after injury. After 24 hours the fracture is more difficult to reduce because of edema and scar formation. Then reduction may be delayed for several days until edema is gone. Simple closed fractures may not need surgical intervention. Management focuses on pain relief and cold compresses to decrease swelling.

Pre-Op Drugs

Drug types for preoperative purposes may include sedatives (e.g., hydroxyzine [Atarax, Vistaril]); hypnotics (e.g., lorazepam [Ativan]); anxiolytics (e.g., midazolam [Versed]); opioid analgesics (e.g., morphine, hydromorphone); and an anticholinergic agent (e.g., atropine). Other specific-purpose drugs also may be added. For example, if rapid emptying of the stomach is needed, metoclopramide (Reglan) may be prescribed. When procedures are long or stress ulcers are likely, an H2 histamine blocker (e.g., cimetidine [Tagamet]; ranitidine [Zantac]) is used. The surgeon may prescribe a prophylactic antibiotic to be given right before or during surgery to reduce the risk for a surgical site infection, as suggested by The Joint Commission's NPSGs. When needed, the antibiotic is given within 60 minutes before the incision is made, as mandated by the Surgical Care Improvement Project (SCIP) core measures, SCIP Inf-1

Drug Use Affecting the Respiratory System

Drug use, both prescribed drugs and illicit drugs, can affect lung function, even when taken systemically. Ask about drugs taken for breathing problems and those taken for other conditions. For example, a cough can be a side effect of some antihypertensive drugs (angiotensin-converting enzyme inhibitors [ACEIs] and angiotensin receptor blockers [ARBs]). Determine which over-the-counter drugs (e.g., cough syrups, antihistamines, decongestants, inhalants) the patient uses. Assess use of complementary and integrative therapies. Ask about past drug use. Some drugs for other conditions can cause permanent changes in lung function. For example, patients may have pulmonary fibrosis if they received bleomycin (Blenoxane) as chemotherapy for cancer or amiodarone (Cordarone) for cardiac problems. Marijuana and illicit drugs, such as cocaine, are often inhaled and can affect lung function.

Asthma Physical Assessment

During an acute episode, common symptoms 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. 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.

Endoscopic Examinations

Endoscopic studies to assess breathing problems include bronchoscopy, laryngoscopy, and mediastinoscopy. With laryngoscopy, a tube for visualization is inserted into the larynx to assess the function of the vocal cords, remove foreign bodies caught in the larynx, or obtain tissue samples for biopsy or culture. A mediastinoscopy is the insertion of a flexible tube through the chest wall just above the sternum into the area between the lungs. It is performed in the operating room with the patient under general anesthesia to examine for the presence of tumors and obtain tissue samples for biopsy or culture. Most complications are related to the anesthetic agents and bleeding.

Active Transport

Energy required -critical in electrolyte movement such as the sodium potassium pump

LMWH (low molecular weight heparin)

Enoxaparin Inhibit thrombin formation More predictable no labs required Monitor for improvement or complications

Endocrine disease and hypertension

Focus is in the adrenal gland. Aldosterone plays a huge role in BP. Sodium, water, and BP go together.

Fluid Overload Nursing Diagnosis

Excess fluid volume Risk for imbalanced fluid volume Decreased cardiac output Fatigue

Tracheoesophageal fistula (TEF)

Excessive cuff pressure causes erosion of the posterior wall of the trachea and loss of TISSUE INTEGRITY. A hole is created between the trachea and the anterior esophagus. The patient at highest risk also has a nasogastric tube present. Similar to tracheomalacia: Food particles are seen in tracheal secretions. Increased air in cuff is needed to achieve a seal. The patient has increased coughing and choking while eating. The patient does not receive the set tidal volume on the ventilator. Manually administer oxygen by mask to prevent hypoxemia. Use a small, soft feeding tube instead of a nasogastric tube for tube feedings. A gastrostomy or jejunostomy may be performed by the physician. Monitor the patient with a nasogastric tube closely; assess for TEF and aspiration. Maintain cuff pressure. Monitor the amount of air needed for inflation and detect changes. Progress to a deflated cuff or cuffless tube as soon as possible.

Tracheostomy Weaning

First, the cuff is deflated as soon as the patient can manage secretions and does not need mechanical ventilation. This change allows him or her to breathe through the tube and through the upper airway. Next, the tube is changed to an uncuffed tube. If this is tolerated, the size of the tube is gradually decreased. When a small fenestrated tube is placed, the tube is capped so all air passes through the upper airway and the fenestra, with none passing through the tube. Assess the patient to ensure adequate airflow around the tube when it is capped. The tube may be removed after he or she tolerates more than 24 hours of capping. Place a dry dressing over the stoma (which gradually heals on its own). Another device used for the transition from tracheostomy to natural breathing is a tracheostomy button. The button maintains stoma patency and assists spontaneous breathing. The Kistner tracheostomy tube and Olympic tracheostomy button are examples of this type of device. To function, the button must fit properly. A disadvantage is the possibility of covert decannulation (i.e., the tube can dislodge from the trachea but remain in the neck tissues).

How to Use a Dry Powder Inhaler (DPI)

For Inhalers Requiring Loading • First load the drug by: • Turning the device to the next dose of drug, or • Inserting the capsule into the device, or • Inserting the disk or compartment into the device After Loading the Drug and for Inhalers That Do Not Require Drug Loading • Read your doctor's instructions for how fast you should breathe for your particular inhaler. • Exhale fully away from the inhaler. • Place your lips over the mouthpiece and breathe in forcefully (there is no propellant in the inhaler; only your breath pulls the drug in). • Remove the inhaler from your mouth as soon as you have breathed in. • Never exhale (breathe out) into your inhaler. Your breath will moisten the powder, causing it to clump and not be delivered accurately. • Never wash or place the inhaler in water. • Never shake your inhaler. • Keep your inhaler in a dry place at room temperature. • If the inhaler is preloaded, discard it after it is empty. • Because the drug is a dry powder and there is no propellant, you may not feel, smell, or taste it as you inhale.

GERD and asthma

Gastroesophageal reflux disease (GERD) can trigger asthma in some adults and causes asthma symptoms at night (Global Initiative for Asthma [GINA], 2017). With GERD, highly acidic stomach contents enter the airway and make pre-existing tissue sensitivity worse

Patient and Family Education: Preparing for Self-Management Venous Insufficiency

Graduated Compression Stockings (GCSs) • Wear stockings as prescribed, usually during the day and evening. • Put the stockings on upon awakening and before getting out of bed. • When applying the stockings, do not "bunch up" and apply like socks. Instead, place your hand inside the stocking and pull out the heel. Then place the foot of the stocking over your foot and slide the rest of the stocking up. Be sure that rough seams on the stocking are on the outside, not next to your skin. • Do not push stockings down for comfort because they may function like a tourniquet and further impair venous return. • Put on a clean pair of stockings each day. Wash them by hand (not in a washing machine) in a gentle detergent and warm water. • If the stockings seem to be "stretched out," replace them with a new pair. • Be sure to assess sizing if the patient has gained or lost weight. Dos and Don'ts • Elevate your legs for at least 20 minutes 4 or 5 times a day. When in bed, elevate your legs above the level of your heart. • Avoid prolonged sitting or standing. • Do not cross your legs. Crossing at the ankles is acceptable for short periods. • Do not wear tight, restrictive pants. Avoid girdles and garters.

Klebsiella pneumoniae

Gram negative bacteria from intestinal tract Carbapenem Resistant causes pneumonia r/t HAI Symptoms: thick sputum, cough, chest pain, trouble breathing, chills, fever Need a sputum culture Can cause infection anywhere Seen in patients with devices such as ventilators

Gum chewing post op

Gum chewing in the early postoperative period has been suggested to promote intestinal peristalsis. Chewing gum stimulates digestive secretions, including gastric hormones that trigger increased motility without adding bulk to the GI system. A variety of nursing studies report this strategy to be acceptable to patients, low-cost, and successful in returning intestinal peristalsis after abdominal surgery

Diuretics

HCTZ, furosemide are potassium wasting spironolactone is potassium sparing

Commonly Used Drugs for Lowering LDL-C Levels

HMG-CoA REDUCTASE INHIBITORS (STATINS) • Lovastatin (Mevacor) • Atorvastatin (Lipitor) • Simvastatin (Zocor) • Fluvastatin (Lescol) • Rosuvastatin (Crestor) • Pravastatin (Pravachol) • Pitavastatin (Livalo) COMBINATION DRUGS • Ezetimibe and simvastatin (Vytorin) • Amlodipine and atorvastatin (Caduet) • Niacin and lovastatin (Advicor)

Head and Neck Cancer

Head and neck cancer can disrupt breathing (GAS EXCHANGE), eating, facial appearance, self-image, speech, and communication. This form of cancer can be devastating, even when cured. The care needs for patients with these problems are complex, requiring a coordinated interprofessional team approach. Common team members include an oncologist, surgeon, nurse, registered dietitian, speech and language pathologist, dentist, respiratory therapist, social worker, wound care specialist, clergy, occupational and physical therapists, and psychosocial counselors. The two most important risk factors for head and neck cancer are tobacco and alcohol use, especially in combination. Other risk factors include voice abuse, chronic laryngitis, exposure to chemicals or dusts, poor oral hygiene, long-term gastroesophageal reflux disease, and oral infection with the human papillomavirus (HPV)

Lung Cancer Pulmonary Signs and Symptoms

Heart sounds may be muffled by a tumor or fluid around the heart (cardiac tamponade). Dysrhythmias may occur as a result of hypoxemia or direct pressure of the tumor on the heart. Cyanosis of the lips and fingertips or clubbing of the fingers may be present. Bones lose density with tumor invasion and break easily. The patient may have bone pain or pathologic fractures. Handle him or her carefully. Thin bones can fracture with little pressure and without trauma. Even heavy coughing can break a rib. Late symptoms of lung cancer usually include fatigue, weight loss, anorexia, dysphagia, and nausea and vomiting. Superior vena cava syndrome may result from tumor pressure in or around the vena cava. This syndrome is an emergency and requires immediate intervention. The patient may have confusion or personality changes from brain metastasis. Bowel and bladder tone or function may be affected by tumor spread to the spine and spinal cord, which can change gait.

Importance of Electrolytes

Help create electricity or energy for body function -cell excitability -nerve impulse transmission Narrow range of normal

Essential hypertension

High blood pressure with no verifiable physical cause, which makes up the overwhelming majority of high blood pressure cases. Also called Primary Hypertension.

Moderate Sedation Ex: Versed

IV delivery of drugs to reduce LOC sedatives, hypnotics, opioids Patient maintains patent airway, can respond to verbal commands For short term diagnostic procedures

Patient-controlled analgesia (PCA)

IV infusion or internal pump (the catheter is sutured into or near the surgical area) and epidural analgesia are often used for better pain control. In PCA the patient adjusts the dosage of the analgesic based on the pain level and response to the drug. This method allows more consistent pain relief and more control by the patient. The maximum dose per hour is "locked in" to the pump so the patient cannot accidentally overdose. Common drugs used in PCA include morphine and hydromorphone.

NSAIDs

Ibuprofen (Motrin, Novo-Profen), naproxen (Naprosyn, Nu-Naprox), and celecoxib (Celebrex) are the most widely used oral NSAIDs in the United States and Canada. Diclofenac (Voltaren) is prescribed in patch and gel form for topical administration. An intranasal patient-controlled formulation of ketorolac (Sprix) has been approved for short-term treatment of acute pain. IV formulations of ketorolac (Toradol), ibuprofen (Caldolor), and diclofenac (Dyloject) are also used to manage acute pain. Each have been shown to produce excellent analgesia alone for mild-to-moderate nociceptive pain and significant opioid dose-sparing effects when administered as part of a multimodal analgesic plan for more severe pain.

Idiopathic Pulmonary Fibrosis

Idiopathic pulmonary fibrosis is a common restrictive lung disease. The patient usually is an older adult with a history of cigarette smoking, chronic exposure to inhalation irritants, or exposure to the drugs amiodarone (Cordarone) or ambrisentan (Letairis, Volibris). Most patients have progressive disease with few remission periods. Even with proper treatment, most patients usually survive less than 5 years after diagnosis. Pulmonary fibrosis is an example of excessive wound healing with loss of CELLULAR REGULATION. Once lung injury occurs, inflammation begins tissue repair. The inflammation continues beyond normal healing time, causing fibrosis and scarring. These changes thicken alveolar tissues, making GAS EXCHANGE difficult.

Oxygen Therapy Summary

In addition to being an essential body nutrient, oxygen (O2) is a gas used as a drug for relief of hypoxemia (low levels of oxygen in the blood) and hypoxia (decreased tissue oxygenation). The oxygen content of atmospheric air is about 21%. Oxygen therapy is prescribed for both acute and chronic breathing problems when the patient's oxygen needs cannot be met by atmospheric ("room") air alone. Indications for use include decreased partial pressure of arterial oxygen (PaO2) levels or decreased arterial oxygen saturation (SaO2). Nonrespiratory conditions, such as heart failure, sepsis, fever, and decreased hemoglobin levels or poor hemoglobin quality, can affect GAS EXCHANGE and also are indications for oxygen therapy. These conditions increase oxygen demand, decrease the oxygen-carrying capability of the blood, or decrease cardiac output. The purpose of oxygen therapy is to use the lowest fraction of inspired oxygen (FiO2) to have an acceptable blood oxygen level without causing harmful side effects. Although oxygen improves the PaO2 level, it does not cure the problem or stop the disease process. Most patients with hypoxia require an oxygen flow of 2 to 4 L/min via nasal cannula or up to 40% via Venturi mask to achieve an oxygen saturation of at least 95%. For a patient who is hypoxemic and has chronic hypercarbia (increased partial pressure of arterial carbon dioxide [PaCO2] levels), the FiO2 delivered should be titrated to correct the hypoxemia and achieve generally acceptable oxygen saturations in the range of 88% to 92%.

VTE surgical management

In order to meet surgical requirements: Pt. must have recurrent DVT, no response to medical management, and is not a candidate for anticoagulation (poor kidney function) Thrombectomy is the surgery

PACU 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.

Acute Pain Responses

Increased heart rate Increased blood pressure Increased respiratory rate Dilated pupils Sweating

Tracheostomy Infection

Infection can occur at any time. In the hospital, use sterile technique to prevent infection during suctioning and tracheostomy care. Assess the stoma site at least once every 8 hours for purulent drainage, redness, pain, swelling, or loss of TISSUE INTEGRITY. Tracheostomy dressings may be used to keep the stoma clean and dry. These dressings resemble a 4 × 4 gauze pad with an area removed to fit around the tube. If tracheostomy dressings are not available, fold standard sterile 4 × 4s to fit around the tube. Do not cut the dressing because small bits of gauze could then be aspirated through the tube. Change these dressings often because moist dressings provide a medium for bacterial growth.

inflammation and asthma

Inflammation triggers asthma for some adults when allergens bind to specific antibodies (especially immunoglobulin E [IgE]). Some chemicals, such as histamine, start an immediate inflammatory response, which can be blocked by drugs such as diphenhydramine (Benadryl). Others, such as leukotriene and eotaxin, are slower and cause later, prolonged inflammatory responses, which can be blocked by drugs such as montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo). Chemicals also attract more WBCs to the area, which then continue the responses of blood vessel dilation and capillary leak, causing 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.

Initial and Secondary Tuberculosis

Initial infection is seen more often in the middle or lower lobes of the lung. The local lymph nodes are infected and enlarged. An asymptomatic period usually follows the primary infection and can last for years or decades before clinical symptoms develop. This is called latent TB. An infected person is not contagious to others until symptoms of disease occur. Secondary TB is a reactivation of the disease in a previously infected person. It is more likely when defenses are lowered and IMMUNITY is reduced. This is seen in older adults, those with chronic diseases, and especially those with HIV disease. The upper lobes are common sites of reactivation.

Pneumothorax and Hemothorax Interventions

Initial management of a tension pneumothorax is an immediate needle thoracostomy, with a large-bore needle inserted by the primary health care provider into the second intercostal space in the midclavicular line of the affected side. A chest tube then is placed into the fourth intercostal space, and the other end is attached to a water-seal drainage system until the lung re-inflates. Interventions for hemothorax include chest tube placement to remove the blood in the pleural space to normalize breathing and prevent infection. Closely monitor the chest tube drainage. Serial chest x-rays are used to determine treatment effectiveness. Other care includes pain control, pulmonary hygiene, and continued assessment for respiratory failure. An open thoracotomy is needed when there is initial blood loss of 1000 mL from the chest or persistent bleeding at the rate of 150 to 200 mL/hr over 3 to 4 hours. Monitor the vital signs, blood loss, and intake and output. Assess the patient's response to the chest tubes and infuse IV fluids and blood as prescribed. The blood lost through chest drainage can be infused back into the patient after processing if needed.

General-Innate Immunity Cont.

Innate immunity and inflammation work together. -cells trigger inflammatory response and phagocytosis Cells involved: neutrophils, macrophage, basophils, eosinophils, mast cells

Assessment of the Nose and Sinuses

Inspect the patient's external nose for deformities or polyps and the nares for symmetry of size and shape. To observe the interior nose, ask the patient to tilt the head back for a penlight examination. The experienced nurse may use a nasal speculum and nasopharyngeal mirror for a more thorough inspection of the nasal cavity. Inspect for color, swelling, drainage, and bleeding. Nasal mucous membranes normally appear redder than the oral mucosa but are pale, engorged, and bluish-gray in patients with allergic rhinitis. Check the nasal septum for bleeding, perforation, or deviation. Septal deviation is common and appears as an S shape, tilting toward one side or the other. A perforated septum is present if the light shines through the perforation into the opposite side; this condition is often found in cocaine users. Nasal polyps are pale, shiny, gelatinous lumps or "bags" attached to the turbinates. Block one naris at a time to check how well air moves through the unblocked side.

Nursing Implications: Ethambutol (EMB, Etibi , Myambutol) Inhibits bacterial RNA synthesis, thus suppressing bacterial growth Slow acting and bacteriostatic rather than bactericidal; thus it must be used in combination with other anti-TB drugs

Instruct patients to report any changes in vision, such as reduced color vision, blurred vision, or reduced visual fields, immediately to his or her primary health care provider because the drug can cause optic neuritis, especially at high doses, and can lead to blindness. Minor eye problems are usually reversed when the drug is stopped. Remind the patient to avoid drinking alcoholic beverages while on this drug because the drug induces severe nausea and vomiting when alcohol is ingested. (At one time ethambutol was used as drug therapy to help alcoholic patients stop drinking because of the drug's side effects in association with alcohol.) Ask whether the patient has ever had gout because the drug increases uric acid formation and will make gout worse. Instruct patients to drink at least 8 ounces of water when taking this drug and to increase fluid intake to prevent uric acid from precipitating, making gout or kidney problems worse.

Pleural Friction Rub

Loud, rough, grating, scratching sounds caused by the inflamed surfaces of the pleura rubbing together; often associated with pain on deep inspirations Heard in lateral lung fields Pleurisy Tuberculosis Pulmonary infarction Pneumonia Lung cancer

Pneumonia Assessment

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 patient with hypoxia and reduced GAS EXCHANGE may be uncomfortable in a lying position and will sit upright, balancing with the hands ("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. The patient with pneumonia, especially the older adult, is often hypotensive with orthostatic changes because of vasodilation and dehydration. A rapid, weak pulse may indicate hypoxemia, dehydration, or impending sepsis and shock. Dysrhythmias may occur from cardiac tissue hypoxia.

Why is microbiology important?

Microbiologists look at how many bacteria so they can correctly diagnose and treat using evidence based practice. It is important when obtaining a sample to prevent contamination because that can delay treatment to the patient. Education is important in regards to preventing the spread of infections and promoting positive outcomes

Codeine sulfate, codeine phosphate (Paveral) Monitor for..

Monitor respiratory status because respiratory depression can occur. Monitor GI motility because constipation when taking this drug is common and interventions may be indicated

How often should you monitor surgical incisions?

Monitor surgical incisions at least every 8 hours to recognize an impending evisceration. When a surgical wound evisceration occurs, respond by attending to the patient while another nurse immediately notifies the surgeon.

Ibuprofen (Motrin, Amersol, Novoprofen) Monitor for..

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

COPD Interventions

Monitoring Breathing Techniques Positioning Effective Coughing Oxygen Therapy Drug Therapy Exercise Suctioning Hydration Vibratory Positive Expiratory Pressure Device

General Innate Immunity: WBC Macrophage

Monocyte- immature 2-8% Function: -start immediate inflammatory response -stimulates longer lasting immune response (antibody and cell mediated immunity) -phagocytosis, repair, antigen control -recognizing non self cells Can take part in many phagocytic events, unlike neutrophils which is just 1 event

Chest Trauma

Most can be treated with basic resuscitation, intubation, or chest tube placement. The first emergency approach to all chest injuries is ABC (airway, breathing, circulation), a rapid assessment and treatment of life-threatening conditions

Lung Cancer Pathophysiology

Most primary lung cancers arise as a result of failure of CELLULAR REGULATION in the bronchial epithelium. These cancers are collectively called bronchogenic carcinomas. Lung cancers are classified as small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). Metastasis (spread) of lung cancer occurs by direct extension, through the blood, and by invading lymph glands and vessels. Tumors in the bronchial tubes can grow and obstruct the bronchus partially or completely. Tumors in other areas of lung tissue can grow so large that they can compress and obstruct the airway. Compression of the alveoli, nerves, blood vessels, and lymph vessels can occur and also interfere with GAS EXCHANGE. Lung cancer can spread to the lung lymph nodes; distant lymph nodes; and other tissues, including bone, liver, brain, and adrenal glands. Additional symptoms, known as paraneoplastic syndromes, complicate certain lung cancers. The paraneoplastic syndromes are caused by hormones secreted by tumor cells and occur most commonly with SCLC

Pandemic Influenza

Mostly prevalent among animals and birds; virus can mutate becoming infectious to humans Example: H1N1 (swine flu) Strict isolation precautions Antiviral drugs oseltamivir (Tamiflu), zanamivir (Relenza)

Electrical and fire SAFETY

Multiple outlets on separate circuits are required to avoid overloads that prevent short circuits and the potential loss of power. The nurse ensures safety through the use of electrical equipment that meets specific standards. All equipment used during surgery must be functional and in proper working condition as determined by the safety procedure of that facility. Electrosurgical devices are a primary energy source in the OR. Proper placement of grounding pads; inspection of the electrosurgical device; and avoiding patient contact with metal components of the OR table, other electrical equipment, or pooling preparation solutions help to prevent surgical burns and injury. All OR personnel strive to prevent fire and complications from the use of electrical devices or hazardous substances. Ignition sources, oxidizers, and fuels (commonly referred to as the fire triangle; Fig. 15-1A) are present in the OR and increase the risk for fires (Seifert et al., 2015). Such events are rare but can occur during any procedure. Completing a fire risk assessment for each patient is critical to determine the likelihood for a fire occurrence. Eliminating any elements of the fire triangle avoids or minimizes the risk for injury (see Fig. 15-1B). Managing room temperature (between 68° and 73° F [20° to 23° C]) and humidity (30% to 60%) at recommended levels is optimal for fire SAFETY (AORN, 2015a). The entire surgical team must remain knowledgeable of emergency measures to take in the event of a fire.

Respiratory Changes Associated With Aging: Pharynx and Larynx

Muscles atrophy. Vocal cords become slack. Laryngeal muscles lose elasticity, and airways lose cartilage. interventions: Have face-to-face conversations with patient when possible. Patient's voice may be soft and difficult to understand.

Cell-mediated immunity (CMI)

NO ANTIBODIES Immune System response to antigens that do not evoke antibody mediated response Adaptive/Acquired T cells-NK Cells: Helper T cells, Memory T cells, Cytotoxic T cell, Suppressor T cell Hijacks cell and uses it as a host The virus gives itself away because it shows the proteins on the outside *Antigens activate T cells, which is the PRIMARY cellular response REgulate antibody mediated immunity and innate immunity with inflammation by producing and releasing cytokines then lead to apoptosis which is important in preventing cancer and mets (Helper T cells bind with antigen and destroy or release toxins and goes through apoptosis)

NSAIDS Drug Alert

NSAIDs can cause GI disturbances and decrease platelet aggregation (clotting), which can result in bleeding. Therefore observe the patient for gastric discomfort or vomiting and for bleeding or bruising. Tell the patient and family to stop taking these drugs and report these effects to the primary health care provider immediately if any of these problems occur. Celecoxib has no effect on bleeding time and produces less GI toxicity compared with other NSAIDs. Older adults are at increased risk for NSAID-induced GI toxicity. Acetaminophen should be used for mild pain. If an NSAID is needed for inflammatory pain or additional analgesia, the least ulcer-causing NSAID is recommended. The addition of a proton pump inhibitor (e.g., lansoprazole, omeprazole) to NSAID therapy or use of opioid analgesics rather than an NSAID is recommended for high-risk patients. Topical NSAIDs may be used as needed, especially for musculoskeletal disorder pain

Trachial stenosis

Narrowed tracheal lumen is caused by scar formation from irritation of tracheal mucosa and impaired tissue integrity by the cuff. Stenosis is usually seen after the cuff is deflated or the tracheostomy tube is removed. The patient has increased coughing, inability to expectorate secretions, or difficulty breathing or talking. Tracheal dilation or surgical intervention is used. Prevent pulling of and traction on the tracheostomy tube. Properly secure the tube in the midline position. Maintain proper cuff pressure. Minimize oronasal intubation time.

Nasoseptoplasty

Nasoseptoplasty, or submucous resection (SMR), may be needed to straighten a deviated septum when chronic symptoms or discomfort occurs. Slight nasal septum deviation causes no symptoms. Major deviations may obstruct the nasal passages or interfere with airflow and sinus drainage. The deviated section of cartilage and bone is removed or reshaped as an ambulatory surgical procedure. Nursing care is similar to that for a rhinoplasty.

passive transport

No energy required -filtration= movement of solvents due to water pressure -osmosis= fluid balance -diffusion= solute balance

OA Management

Non surgical: weight loss, PT, rest, Drug therapy such as acetaminophen, aspercreme (topical), and lidocaine patches which are contraindicated with class 1 antiarrhythmics (procainamide), older NSAIDS with a low dose and monitor GI, bleed, and kidney problems. Topical NSAIDs are safe, cortisone injections 4x a yr, muscle relaxants such as flexural, and weak opioids such as tramadol lab work needs to be done before starting NSAIDS

Nonopioid drugs

Nonopioid drugs are appropriate alone for mild-to-moderate nociceptive pain (e.g., from surgery, trauma, or osteoarthritis) or are added to opioids, local anesthetics, and/or anticonvulsants as part of a multimodal analgesic regimen for more severe nociceptive pain. However, they have limited benefit for neuropathic pain. The nonopioids are often combined in a single tablet with opioids such as oxycodone (Percocet) or hydrocodone (Vicodin, Norco, Vicoprofen) and are very popular for the treatment of mild-to-moderate acute pain.

Cystic Fibrosis Assessment

Nonpulmonary symptoms include abdominal distention, gastroesophageal reflux, rectal prolapse, foul-smelling stools, and steatorrhea (excessive fat in stools). The patient is often malnourished and has many vitamin deficiencies, especially of the fat-soluble vitamins (e.g., vitamins A, D, E, K). As pancreatic function decreases, diabetes mellitus develops with loss of insulin production. The adult with severe CF is usually smaller and thinner than average. Another problem seen in adults with CF is the early onset of osteoporosis and osteopenia, with a greatly increased risk for bone fracture. Pulmonary symptoms caused by CF are progressive. Respiratory infections are frequent or chronic with exacerbations. Patients usually have chest congestion, limited exercise tolerance, cough, sputum production, use of accessory muscles, and decreased pulmonary function (especially forced vital capacity [FVC] and forced expiratory volume in the first second of exhalation [FEV1]). Chest x-rays show infiltrate and an increased anteroposterior (AP) diameter. During an acute exacerbation or when the disease progresses to end stage, the patient has increased chest congestion, reduced activity tolerance, increased crackles, increased cough, increased sputum production (often with hemoptysis), and severe dyspnea with fatigue. Arterial blood gas (ABG) studies show acidosis (low pH), greatly reduced arterial oxygen (PaO2) levels, increased arterial carbon dioxide (PaCO2) levels, and increased bicarbonate levels. With infection, the patient has fever, an elevated white blood cell count, and decreased oxygen saturation. Other symptoms of infection include tachypnea, tachycardia, intercostal retractions, weight loss, and increased fatigue.

Sodium functions

Normal 136-135 Controls fluid movement in the body Nerve impulse conduction Heart and Muscle Contraction Decides where water moves Sodium and water go everywhere together

2. Is the CO2 normal?

Normal range is 35-45 acidosis is greater than 45 alkalosis is less than 35

epistaxis (nosebleed)

Nosebleeds occur as a result of trauma, hypertension, blood dyscrasia (e.g., leukemia), inflammation, tumor, decreased humidity, nose blowing, nose picking, chronic cocaine use, and procedures such as nasogastric suctioning.

Notify the health care provider if the aPTT value is greater than....

Notify the health care provider if the aPTT value is greater than 70 seconds or follow hospital protocol for reporting critical laboratory values. Assess patient for signs and symptoms of bleeding, which include hematuria, frank or occult blood in the stool, ecchymosis (bruising), petechiae, an altered level of consciousness, or pain. If bleeding occurs, stop the anticoagulant immediately and call the health care provider or Rapid Response Team!

Post-Op Neuro Assessment

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. Assess 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).

Assessment of the Lungs and Thorax: Inspection

Observe the rate, rhythm, and depth of inspirations and the symmetry of chest movement. Impaired movement or unequal expansion may indicate disease. Observe the type of breathing (e.g., pursed-lip or diaphragmatic breathing) and the use of accessory muscles. Examine the shape of the patient's chest, and compare the anteroposterior (AP or front-to-back) diameter with the lateral (side-to-side) diameter. This ratio normally is about 1 : 1.5, depending on body build. It increases to 1 : 1 in patients with emphysema, which results in the typical barrel-chest appearance. Normally the ribs slope downward. Patients with air trapping in the lungs caused by emphysema have ribs that are more horizontal.

Subclavian Steal

Occurs in upper extremities as result of subclavian artery occlusion or stenosis causing ischemia in the arm and pain; paresthesias and dizziness are also common; blood pressure difference in arms and presence of subclavian bruit on the affected side Treatment: Surgical interventions for cyanosis or unrelenting pain, such as endarterectomy, bypass, or dilation of subclavian arteryMonitor patient closely for new signs and symptoms; postoperative, check pulses and observe for ischemic changes, including severe pain or color changes (e.g., cyanosis).

Airway Obstruction Prevention

One preventable cause of airway obstruction leading to asphyxiation is inspissated (thickly crusted) oral and nasopharyngeal secretions. In this condition, poor oral hygiene leads to thickening and hardening of secretions that can completely block the airway and lead to death. Proper nursing care can eliminate this cause of airway obstruction. Patients at highest risk are those who have an altered mental status and level of consciousness, are dehydrated, are unable to communicate, are unable to cough effectively, or are at risk for aspiration. Assess the oral care needs of the patient with risk factors for inspissated (thickly crusted) secretions daily. Ensure that whoever provides oral care understands the importance and the correct techniques for preventing secretion buildup and airway obstruction.

Assessing cyanosis in dark skin

Only severe cyanosis is evident in the skin of dark-skinned patients. To detect cyanosis, assess the skin and nail beds for a dull, lifeless color. The soles of the feet and the toenails are less pigmented and allow detection of cyanosis or duskiness in the lower extremities.

Hospital acquired pneumonia

Onset/diagnosis of pneumonia >48 hours after admission to hospital Encourage pulmonary hygiene and progressive ambulation Provide adequate hydration Assess risk for aspiration using an evidence-based tool Monitor for early signs of sepsis Hand hygiene is critical Provide vigorous oral care

Health care-associated pneumonia

Onset/diagnosis of pneumonia occurs <48 hours after admission in patient with specific risk factors: • In hospital for >48 hours in the past 90 days • Living in nursing home or assisted-living facility • Received IV therapy, wound care, antibiotics, chemotherapy in the past 30 days • Seen at a hospital or dialysis clinic within the past 30 days May have multidrug-resistant organisms Hand hygiene critical

ventilator associated pneumonia

Onset/diagnosis of pneumonia within 48-72 hours after endotracheal intubation Presence of ET tube increases risk for pneumonia by bypassing protective airway mechanisms and allowing aspiration of secretions from the oropharynx and stomach; dental plaque also increases risk Initiate ventilator bundle order set, including: Elevate HOB at least 30 degrees Daily sedation "vacation" and weaning assessment DVT prophylaxis Oral care regimen Stress ulcer prophylaxis Suctioning, either as needed or continuous subglottal suction Hand hygiene is critical

Compensation

Opposite system used to achieve balance. Respiratory problem helped by metabolic system Metabolic problem helped by respiratory system Kidneys can act by redistributing HCO3 or elimination H+ Respiratory system primarily responds by increasing or decreasing RR. Hyperventilation eliminates CO2 and hypoventilation retains CO2

Immediate Postoperative Neurologic Assessment: Return to Preoperative Level

Order of Return to Consciousness After General Anesthesia 1. Muscular irritability 2. Restlessness and delirium 3. Recognition of pain 4. Ability to reason and control behavior Order of Return of Motor and Sensory Functioning After Local or Regional Anesthesia 1. Sense of touch 2. Sense of pain 3. Sense of warmth 4. Sense of cold 5. Ability to move

Hyponatremia Interventions

Orthostatic hypotension, Tachycardia, Lethargy, Twitching, Seizures, Coma Interventions: Monitor Input and output, daily weights, skin turgor, fluid restriction per orders, safety, seizure precautions. sports drinks, isotonic IVF.. hypertonic RARELY, stop furosemide or other diuretics

Pre-op assessment

Overall goal: Identify risk factors and plan care to ensure patient safety throughout surgical experience: -determine pt psych status to reinforce use of coping strategies (hope is strongest method of coping) during surgical experience; note, surgery may elicit stress response (incr. BP, HR, etc.) which enables body to prepare to meet demands in preoperative period; decrease stress and anxiety by telling patient about what they can expect -determine physiologic factors that are directly or indirectly related to the surgical procedure and may contribute to the outpatient risk factors; aka health history -establish baseline data for comparison -ID and document surgical site/ side of body -ID prescription meds, OTC meds, herbal supplements taken by pt that may interact with anesthesia or any possible surgical outcomes -document results of pre-op lab and diagnostic tests and communicate this with health care team -ID cultural and ethnic factors that may affect surgical experience -determine if pt has received adequate info from surgeon to make an informed decision and if consent is signed and witnessed

Inhalation Anthrax Stages

PRODROMAL STAGE (EARLY) • Fever • Fatigue • Mild chest pain • Dry cough • No signs or symptoms of upper respiratory infection • Mediastinal "widening" on chest x-ray FULMINANT STAGE (LATE) • Sudden onset of breathlessness • Dyspnea • Diaphoresis • Stridor on inhalation and exhalation • Hypoxia • High fever • Mediastinitis • Pleural effusion • Hypotension • Septic shock

Arterial Blood Gases

PaO2 80-100 mm Hg Older adults: values may be lower Elevations indicate possible excessive oxygen administration. Decreased levels indicate possible COPD, asthma, chronic bronchitis, cancer of the bronchi and lungs, cystic fibrosis, respiratory distress syndrome, anemias, atelectasis, or any other cause of hypoxia. PaCO2 35-45 mm Hg Elevations indicate possible COPD, asthma, pneumonia, anesthesia effects, or use of opioids (respiratory acidosis). Decreased levels indicate hyperventilation/respiratory alkalosis. pH Up to 60 yr: 7.35-7.45 60-90 yr: 7.31-7.42 >90 yr: 7.26-7.43 Elevations indicate metabolic or respiratory alkalosis. Decreased levels indicate metabolic or respiratory acidosis. HCO3 21-28 mEq/L (21-28 mmol/L) Elevations indicate possible respiratory acidosis as compensation for a primary metabolic alkalosis. Decreased levels indicate possible respiratory alkalosis as compensation for a primary metabolic acidosis. SpO2 95%-100% Older adults: values may be slightly lower Decreased levels indicate possible impaired ability of hemoglobin to release oxygen to tissues.

Raynaud's disease

Painful vasospasms of arteries and arterioles in extremities, especially digits; causes red-white-blue skin color changes on exposure to cold or stress; cause unknown, occurs more in women, and may be autoimmune because it is associated with many rheumatic diseases such as systemic lupus erythematosus Treatment: Same as for Buerger's disease

Assessment of the Lungs and Thorax: Palpation

Palpation also can help identify areas of tenderness and check vocal or tactile fremitus (vibration). Unequal expansion may be a result of pain, trauma, or air in the pleural cavity. Respiratory lag or slowed movement on one side indicates a pulmonary problem (Jarvis, 2016). Palpate any abnormalities found on inspection (e.g., masses, lesions, swelling). Also palpate for tenderness, especially if the patient reports pain. Crepitus (air trapped in and under the skin, also known as subcutaneous emphysema) is felt as a crackling sensation beneath the fingertips. Document this finding and report it to the primary health care provider when it occurs around a wound site or a tracheostomy site or if a pneumothorax is suspected. Tactile (vocal) fremitus is felt as a vibration of the chest wall produced when the patient speaks. Fremitus is decreased if sound wave transmission from the larynx to the chest wall is slowed, such as when the pleural space is filled with air (pneumothorax) or fluid (pleural effusion) or when the bronchus is obstructed. Fremitus is increased with pneumonia and lung abscesses

Airway Obstruction Assessment

Partial obstruction produces general symptoms such as diaphoresis, tachycardia, and elevated blood pressure. Observe for hypoxia and hypercarbia, restlessness, increasing anxiety, sternal retractions, a "seesawing" chest, abdominal movements, or a feeling of impending doom from air hunger. Use pulse oximetry or end-tidal carbon dioxide (ETCO2 or PETCO2) for ongoing monitoring of GAS EXCHANGE. Continually assess for stridor, cyanosis, and changes in level of consciousness.

Respiratory Changes Associated With Aging: Muscle Strength

Respiratory muscle strength, especially the diaphragm and the intercostals, decreases. Interventions: Encourage pulmonary hygiene and help patient actively maintain health and fitness. Regular pulmonary hygiene and overall fitness help maintain maximal functioning of the respiratory system and prevent illness.

What are the two main types of microorganisms?

Pathogenic (causes disease) and Nonpathogenic (no disease)

Skin Preparation

Patient may be asked to shower using antiseptic solution. Hair removal is done by electric clippers, NOT SHAVING bc of increased risk for infection. no deodorant, lotions, powders, oils assess allergies

Arterial Ulcers

Patient reports claudication after walking about 1-2 blocks Rest pain usually present Pain at ulcer site Two or three risk factors present End of the toes Between the toes Deep Ulcer bed pale, with even edges Little granulation tissue Cool or cold foot Decreased or absent pulses Atrophy of skin Hair loss Pallor with elevation Dependent rubor Possible gangrene When acute, neurologic deficits noted Treat underlying cause (surgical, revascularization) Prevent trauma and infection Patient education, stressing foot care

Blood Donations

Patients can choose to have their own blood donated, also called autologous donations, up to 3 weeks prior to surgery. Also, patients can have a family member with the same blood type as you which is called direct blood donation. Jehovah's witness do NOT accept blood OR blood products

Post Op SpO2 Monitoring

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. Patients who received moderate sedation with a benzodiazepine such as midazolam (Versed) or lorazepam (Ativan, Nu-Loraz ) 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 impaired GAS EXCHANGE after surgery occurs on the second postoperative day.

VTE Physical Assessment

People with DVT may have symptoms or may be asymptomatic. The classic signs and symptoms of DVT are calf or groin tenderness and pain and sudden onset of unilateral swelling of the leg. Pain in the calf on dorsiflexion of the foot (positive Homans' sign) appears in only a small percentage of patients with DVT, and false-positive findings are common. Therefore checking a Homans' sign is not advised because it is an unreliable tool! Examine the area described as painful, comparing this site with the other limb. Gently palpate the site, observing for induration (hardening) along the blood vessel and for warmth and edema. Redness may also be present. S/S are UNILATERAL.

Peripheral Arterial Disease (PAD)

Peripheral vascular disease (PVD) includes disorders that change the natural flow of blood through the arteries and veins of the peripheral circulation, causing decreased PERFUSION to body tissues. It affects the legs much more frequently than the arms. PAD is a result of systemic atherosclerosis. It is a chronic condition in which partial or total arterial occlusion (blockage) decreases PERFUSION to the extremities. The tissues below the narrowed or obstructed arteries cannot live without an adequate oxygen and nutrient supply. Atherosclerosis is the most common cause of chronic arterial obstruction; therefore the risk factors for atherosclerosis apply to PAD as well (see Table 36-4). Advancing age also increases the risk for disease related to atherosclerosis. Patients with PAD have an increased risk for developing chronic angina, MI, or stroke and are much more likely to die within 10 years than those who do not have the disease (Mozaffarian et al., 2016). About 8.5 million people in the United States, age 40 and older, have PAD. African Americans are affected more often than any other group, most likely because they have many risk factors such as diabetes and hypertension.

Peritonsillar Abscess

Peritonsillar abscess (PTA) is a rare complication of acute tonsillitis. The infection spreads from the tonsil to the surrounding tissue and forms an abscess. The most common cause of PTA is group A beta-hemolytic Streptococcus, although the abscess often contains multiple organisms (Shah, 2014). Signs and symptoms include a collection of pus behind the tonsil causing swelling on one side of the throat, pushing the uvula toward the unaffected side. The patient may have severe throat pain radiating to the ear or teeth, a muffled voice, fever, and difficulty swallowing. He or she may also have a tonic contraction of the muscles of chewing (trismus) and difficulty breathing. Bad breath is present, and lymph nodes on the affected side are swollen. Diagnosis is usually made based on the patient's symptoms, but needle aspiration and culture of pus collected is the preferred test. Most patients can be treated as outpatients with antibiotics. However, antibiotics alone are often ineffective. The patient may need steroids to reduce the swelling, and some may need drainage of the abscess. Pain control is important; drugs may include topical anesthetics, over-the-counter analgesics, and opioids. The patient may need liquid drugs because of swallowing difficulty. Stress the importance of completing the antibiotic regimen and coming to the emergency department quickly if symptoms of obstruction (drooling and stridor) appear. Hospitalization is needed when the airway is endangered or when the infection does not respond to antibiotic therapy. A tonsillectomy may be performed to prevent recurrence.

Post-Operative Period

Phase I care occurs immediately after surgery, most often in a PACU. For patients who have very complicated procedures or many serious health problems, phase I care may occur in an ICU. The length of time the patient remains at a phase I level of care depends on his or her health status, the surgical procedure, anesthesia type, and rate of progression to regain alertness and hemodynamic stability. It can range from less than 1 hour to days. This level requires ongoing monitoring of the airway, vital signs, and evidence of recovery that varies from every 5 to 15 minutes initially. The time between assessments gradually increases as the patient progresses toward recovery. Phase II care focuses on preparing the patient for care in an extended-care environment such as a medical-surgical unit, step-down unit, skilled nursing facility, or home. This phase can occur in a PACU, on a medical-surgical unit, or in the same-day surgery (SDS) unit (ambulatory care unit) and may last only 15 to 30 minutes, although 1 to 2 hours is more typical. Patients are discharged from this phase when presurgery level of consciousness has returned, oxygen saturation is at baseline, and vital signs are stable. Some patients achieve this level of recovery in phase I and can be discharged directly to home. Others may require further observation. Phase III care, known as the extended-care environment, most often occurs on a hospital unit or in the home. For patients who have continuing care needs that cannot be met at home, discharge may be from the hospital unit to an extended-care facility. Although vital signs continue to be monitored in this type of environment, the frequency ranges from several times daily to just once daily.

IgA

Secretory antibody mostly in mucous membranes, respiratory tract, digestive tract, urinary tract, and tears, saliva and breast milk

What is a stent?

Placement of a mesh wire device to hold an artery open and prevent stenosis

VTE Planning and Implementation

Planning: Expected Outcomes. The patient with VTE is expected to remain free of injury from VTE complications and the use of anticoagulant therapy. Interventions. The focus of managing thrombophlebitis is to prevent complications such as pulmonary emboli, further thrombus formation, and an increase in size of the thrombus. Patients with deep vein thrombosis (DVT) may be hospitalized for treatment, although this practice is changing as a result of the use of newer drugs. Nonsurgical Management. DVT is usually treated medically with a combination of rest and drug therapy. Prevention of DVT and other types of VTE is crucial for patients at risk. For those at moderate-to-high risk, initiate these interventions to prevent VTE: • Patient education • Leg exercises • Early ambulation • Adequate hydration • Graduated compression stockings • Intermittent pneumatic compression, such as sequential compression devices (SCDs) • Venous plexus foot pump • Anticoagulant therapy

pleura in the lungs

Pleura: two thin layers with fluid between them that allow frictionless movement Visceral pleura: outer later Parietal pleura: inside layer

Pneumonia

Pneumonia is excess fluid in the lungs from an inflammatory process. This disease can seriously reduce gas exchange. GAS EXCHANGE is oxygen transport to the cells and carbon dioxide transport away from cells through ventilation and diffusion. oxide transport away from cells through ventilation and diffusion. See Chapter 2 for a discussion that summarizes the concept of gas exchange. Inflammation causing pneumonia can be triggered by infectious organisms and by inhaling irritating agents. 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 collect in and around the alveoli, and the alveolar walls thicken. Both events seriously reduce GAS EXCHANGE by interfering with diffusion in the lungs. This leads to hypoxemia, which has the potential to cause 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) reduces GAS EXCHANGE even more. As a result, arterial oxygen levels fall, causing hypoxemia.

Fine crackles Fine rales High-pitched rales

Popping, discontinuous sounds caused by air moving into previously deflated airways; sounds like hair being rolled between fingers near the ear "Velcro" sounds late in inspiration usually associated with restrictive disorders Asbestosis Atelectasis Interstitial fibrosis Bronchitis Pneumonia Chronic pulmonary diseases

Posterior nasal bleeding

Posterior nasal bleeding is an emergency because it cannot be easily reached and the patient may lose a lot of blood quickly (Vacca & Poirier, 2013). Posterior packing, epistaxis catheters (nasal pressure tubes), or gel tampons are used to stop bleeding that originates in the posterior nasal region. With packing, the primary health care provider positions a large gauze pack in the posterior nasal cavity above the throat, threads the attached string through the nose, and tapes it to the patient's cheek to prevent pack movement. Epistaxis catheters look like very short (about 6 inches) urinary catheters. These tubes have an exterior balloon along the tube length in addition to an anchoring balloon on the end. Placement of posterior packing or pressure tubes is uncomfortable; and the airway may be obstructed with reduced GAS EXCHANGE if the pack slips. For posterior bleeds that do not respond to packing or tubes, additional options include cauterizing the blood vessels, ligating the vessels, or performing an embolization of the bleeding artery with interventional radiology. Potential complications of embolization include facial pain, necrosis of skin or nasal mucosa, facial nerve paralysis, and blindness (Poetker, 2013). After the tubes or packing is removed, teach the patient and family these interventions to use at home for comfort and safety: • Petroleum jelly can be applied sparingly to the nares for lubrication and comfort. (Excessive application could cause inhalation of the jelly into the lungs and increase the risk for pneumonia.) • Nasal saline sprays and humidification add moisture and prevent rebleeding. • Avoid vigorous nose blowing, the use of aspirin or other NSAIDs, and strenuous activities such as heavy lifting for at least 1 month.

Post op GI assessment

Postoperative nausea and vomiting (PONV) are among the most common reactions after surgery. 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. Constipation may occur after surgery as a result of anesthesia, analgesia (especially opioids), decreased activity, and decreased oral intake. Assess the abdomen by inspection, auscultation, palpation, and percussion and record the elimination pattern to determine whether intervention is needed. Auscultate before palpation or percussion because these two maneuvers are thought to affect peristalsis. Increased dietary fiber intake, the use of mild laxatives or bulk-forming agents, or the use of enemas may be needed. Encourage ambulation as early as possible after surgery to promote peristalsis Action Alert After gastric surgery do not move or irrigate the NG tube unless ordered.

Arterial Revascularization Post-op Care

Preparing the patient for surgery is similar to procedures described for general or epidural Patients who have undergone conventional aortoiliac or aortofemoral bypass are NPO status for at least 1 day after surgery to prevent nausea and vomiting, which could increase intra-abdominal pressure. Those who have undergone bypass surgery of the lower extremities not involving the aorta or abdominal wall (femoropopliteal or femorotibial bypass) may remain NPO until the first postoperative day, when they are allowed clear liquids. Warmth, redness, and edema of the affected extremity are often expected outcomes of surgery as a result of increased arterial PERFUSION. Immediately after surgery, the operating suite or postanesthesia care unit (PACU) nurse marks the site where the distal (dorsalis pedis or posterior tibial) pulse is best palpated or heard by Doppler ultrasonography. This information is communicated to the nursing staff on the critical care unit where the patient will be sent. "Hand-off" reporting is essential to promote safety and quality care (as required by The Joint Commission's National Patient Safety Goals).

Selected 2013 ACC/AHA Recommendations for the Treatment of Serum Cholesterol to Reduce Atherosclerotic Cardiovascular Disease Risk in Adults

Primary Prevention • All people with LDL-C equal to or greater than 190 mg/dL should be evaluated for secondary causes of hyperlipidemia and treated with statin therapy. • Adults with diabetes mellitus who are 40 to 75 years of age should be treated with high-intensity statin therapy. • Adults 40 to 75 years of age with LDL-C of 70 to 189 mg/dL without clinical signs of ASCVD or diabetes should be treated with moderate- to high-intensity statin therapy. Secondary Prevention • High-intensity statin therapy should be initiated or continued as first-line treatment in adults 75 years of age or younger who have signs and symptoms of ASCVD, unless contraindicated. • In people older than 75 years, the potential for ASCVD risk-reduction benefits, adverse drug effects, and drug-drug interactions should be evaluated.

Preventing hypoxia

Prevent hypoxia by hyperoxygenating the patient with 100% oxygen using a manual resuscitation bag attached to an oxygen source. Instruct the patient to take deep breaths 3 or 4 times with the existing oxygen delivery system before suctioning. Monitor the heart rate or use a pulse oximeter while suctioning to assess tolerance of the procedure. Assess for hypoxia (e.g., increased heart rate and blood pressure, oxygen desaturation, cyanosis, restlessness, anxiety, dysrhythmias). Oxygen saturation below 90% by pulse oximetry indicates hypoxemia. If hypoxia occurs, stop the suctioning procedure. Using the 100% oxygen delivery system, reoxygenate the patient until baseline parameters return. Use a correct-size catheter to reduce the risk for hypoxia and still remove secretions effectively

Prevention of Pulmonary Embolism

Prevention of Pulmonary Embolism • Start passive and active range-of-motion exercises for the extremities of immobilized and postoperative patients. • Ambulate patients soon after surgery. • Use anti-embolism and pneumatic compression stockings and devices after surgery. • Evaluate patient for criteria indicating the need for anticoagulant therapy. • Avoid the use of tight garters, girdles, and constricting clothing. • Prevent pressure under the popliteal space (e.g., do not place a pillow under the knee; instead, use alternating pressure mattress). • Perform a comprehensive assessment of peripheral circulation. • Elevate the affected limb 20 degrees or more above the level of the heart to improve venous return, as appropriate. • Change patient position every 2 hours or ambulate as tolerated. • Prevent injury to the vessel lumen by preventing local pressure, trauma, infection, or sepsis. • Refrain from massaging leg muscles. • Instruct patient not to cross legs. • Administer prescribed prophylactic low-dose anticoagulant and antiplatelet drugs. • Teach the patient to avoid activities that result in the Valsalva maneuver (e.g., breath-holding, bearing down for bowel movements, coughing). • Administer prescribed drugs, such as stool softeners, that will prevent episodes of the Valsalva maneuver. • Teach the patient and family about precautions. • Encourage smoking cessation.

Care of the Patient Who Has an Intrathecal Pump for Managing Cancer Pain

Provide postoperative care and health teaching to include: • Carefully monitor respiratory status, including respiratory rate, oxygen saturation, and level of consciousness every 1 to 2 hours after surgery for at least 12 hours or as per surgeon or agency protocol. • Apply an abdominal binder in place as prescribed to hold the pump in a flat position. • Teach the patient that a burning sensation may occur around the pump area. Cold packs and topical lidocaine may provide COMFORT; do not use heat over the lumbar pump site. • Teach the patient to avoid lifting more than 5 lb or twisting/bending at the waist for 6 weeks or as instructed by the surgeon. Monitor for and teach the patient and family to report these potential complications: • Surgical complications • Infection: Observe for fever and localized redness or hematoma at the lumbar site. • Cerebrospinal (CSF) fluid leak: Ask about headache; observe for swelling without redness at the lumbar site. • Catheter-related complications • Structural damage, including kinks, occlusion, or disconnection; note change in pain control or signs of opioid withdrawal. • Pump-related complications (not common) • Malfunction or displacement: Observe for opioid overdose or underdosing, causing a change in pain control or opioid withdrawal. Keep these safety and care precautions in mind when caring for the patient: • Be sure that the pump is shielded if the patient received external beam radiation. • Be sure that the patient does not have an abrupt discontinuation of baclofen (can cause respiratory depression) or clonidine (can cause hypertension and stroke).

Role of Anesthesiologist

Provides fluids and blood products as needed; medications for anesthesia, analgesia, and blocks; monitors patient during surgery by assessing: • Level of anesthesia (using a peripheral nerve stimulator) • Cardiopulmonary function (electrocardiographic [ECG] monitoring) • Capnography (monitors ventilation for nonintubated patients) • Vital signs • Intake and output

Role of scrub nurse/tech

Provides patient care at the surgical field, assisting the surgeon and assistants; maintains the integrity, safety, and efficiency of the sterile field during the procedure Sets up the sterile field, hands up sterile instrumentation/equipment With the circulating nurse, maintains accurate count of sponges, sharps, and instruments and monitors the amount of irrigation fluid and medication used

Pulmonary Contusion

Pulmonary contusion, a potentially lethal injury, is a common chest injury and occurs most often by rapid deceleration during car crashes. After a contusion, respiratory failure can develop immediately or over time. Hemorrhage and edema occur in and between the alveoli, reducing both lung movement and the area available for GAS EXCHANGE. Localized inflammation can cause further damage. The patient becomes hypoxemic and dyspneic. Patients may be asymptomatic at first and can later develop various degrees of respiratory failure and possibly pneumonia (Landeen & Smith, 2014). These patients often have decreased breath sounds or crackles and wheezes over the affected area. Other symptoms include bruising over the injury, dry cough, tachycardia, tachypnea, and dullness to percussion. At first the chest x-ray may show no abnormalities. A hazy opacity in the lobes or parenchyma may develop over several days. If there is no disruption of the parenchyma, bruise resorption often occurs without treatment. Management includes maintenance of ventilation and GAS EXCHANGE. Provide oxygen, give IV fluids as prescribed, and place the patient in a moderate-Fowler's position. If a high FiO2 is needed, oxygen may be administered using a high-flow nasal cannula (HFNC). When side-lying, the "good lung down" position may be helpful. The patient in obvious respiratory distress may need noninvasive positive-pressure ventilation (NPPV) or mechanical ventilation with positive end-expiratory pressure (PEEP) to inflate the lungs.

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. PFTs are useful in screening patients for lung disease even before the onset of symptoms (Parker, 2014). 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 problems or cardiac problems or by muscle weakness. Patient Preparation.

Pulse Oximetry

Pulse oximetry can detect desaturation before symptoms (e.g., dusky skin, pale mucosa, pale or blue nail beds) occur. Causes for low readings include patient movement, hypothermia, decreased peripheral blood flow, ambient light (sunlight, infrared lamps), decreased hemoglobin, edema, and fingernail polish. When patients have any degree of impaired peripheral blood flow, the most accurate place to test oxygen saturation is on the forehead. Some brands of inexpensive portable oximeters have been shown to produce unreliable results in acutely ill patients compared with arterial blood sampling for SaO2 and should not be used in patients who have known abnormal oxygen saturation values (Jones et al., 2015). Results lower than 91% in an adult who does not have a chronic respiratory problem (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.

Complete Blood Count

Red blood cells Females: 4.2-5.4 million/mm3, or 4.2-5.4 × 1012/L Males: 4.7-6.1 million/mm3, or 4.7-6.1 × 1012/L Elevated levels (polycythemia) are often related to the excessive production of erythropoietin in response to a chronic hypoxic state, as in COPD, and from living at a high altitude. Decreased levels indicate possible anemia, hemorrhage, or hemolysis. Hemoglobin, total Females: 12-16 g/dL, or 120-160 g/L Males: 14-18 g/dL, or 140-180 g/L Same as for red blood cells. Hematocrit Females: 37%-47%, or 0.37-0.47 volume fraction Males: 42%-52%, or 0.42-0.52 volume fraction Same as for red blood cells. WBC count (leukocyte count, WBC count)Total: 5000-10,000/mm3, or 5-10 × 109/L Elevations indicate possible acute infections or inflammations. Decreased levels may indicate an overwhelming infection, an autoimmune disorder, or immunosuppressant therapy.

Angiotensin-Converting Enzyme (ACE) Inhibitors Nursing Implications Common examples of ACE inhibitors: • Lisinopril (Prinivil, Zestril) • Enalapril (Vasotec) • Captopril (Capoten, Apo-Capto )

Report persistent, dry cough to the primary health care provider because this is a common and annoying side effect and another type of antihypertensive medication may be necessary. Monitor BP carefully, especially orthostatic pressures, because these agents result in vasodilation and decreased BP. • Do not give the drug without checking with the health care provider if systolic BP is below 100. Assess for hyperkalemia because ACE inhibitors reduce the excretion of potassium.

emergent surgery

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

Respiratory Changes Associated With Aging: Lungs

Residual volume increases. Vital capacity decreases. Efficiency of oxygen and carbon dioxide exchange decreases. Elasticity decreases. Interventions: Include inspection, palpation, percussion, and auscultation in lung assessments. Inspection, palpation, percussion, and auscultation are needed to detect normal age-related changes. Help patient actively maintain health and fitness. Health and fitness help keep losses in respiratory functioning to a minimum. Assess patient's respirations for abnormal breathing patterns. Periodic breathing patterns (e.g., Cheyne-Stokes) can occur. Encourage frequent oral hygiene. Oral hygiene aids in the removal of secretions.

Recognizing Serious Complications of Spinal and Epidural Anesthesia

Respiratory Depression (Can Occur if the Anesthetic Agent Moves Higher in the Epidural or Subarachnoid Space) • What is the quality and pattern of the breathing? • What is the respiratory rate and depth? • Is the patient receiving oxygen? At which setting and method of delivery? What is the pulse oximetry result? • Notify the anesthesia provider if pulse oximetry drops or if the patient is unable to increase the depth of respiration. Hypotension (Can Occur When Regional Anesthesia Causes Widespread Vasodilation) • What is the patient's blood pressure? • Is the blood pressure now lower than in the preoperative or operative period? • Has the pulse pressure widened? • Notify the anesthesia provider if systolic blood pressure remains more than 10 mm Hg below the patient's baseline or if other manifestations of shock are present. • Notify the anesthesia provider if hypotension is accompanied by other manifestations of autonomic nervous system blockade (bradycardia, nausea, vomiting). Epidural Hematoma • Assess for delayed or regressing return of sensory and motor function. • If return is delayed or is taking longer than usual, alert the anesthesia provider. • Determine whether sensory or motor deficits are improving, remaining the same, or worsening. • If motor deficits are worsening or decreasing after brief improvement, notify the anesthesia provider immediately. • Assess for return of deep tendon reflexes of extremities on both sides. • Compare reflexes from one side of the body with the other. • If reflexes regress, notify the anesthesia provider immediately. • Assess pain level in the back. • If the patient feels pressure or increasing back pain while coughing or straining, notify the anesthesia provider immediately. Infection (Meningitis) • Assess for mental status changes. • Assess for increasing temperature. • Assess for ability to turn the neck. • Notify the anesthesia provider immediately for temperature elevations above 101° F (38.3° C), inability to move the neck, acute confusion. Postdural Puncture Headache • Assess for report of headache in the occipital region, especially when the patient is permitted to sit upright.

Potential System Complications of Surgery

Respiratory System Complications • Atelectasis • Laryngeal edema • Pneumonia • Pulmonary edema • Pulmonary embolism (PE) • Ventilator dependence Cardiovascular Complications • Anaphylaxis • Anemia • Disseminated intravascular coagulation (DIC) • Dysrhythmias • Heart failure • Hypertension • Hypotension • Hypovolemic shock • Sepsis • Venous thromboembolism (VTE), especially deep vein thrombosis (DVT) Neurologic Complications • Cerebral infarction • Cognitive decline • Visual loss Neuromuscular Complications • Hyperthermia • Hypothermia • Joint contractures • Nerve damage and paralysis GI Complications • GI ulcers and bleeding • Paralytic ileus Kidney/Urinary Complications • Acute kidney injury (AKI) • Acute urinary retention • Electrolyte imbalances • Stone formation • Urinary tract infection Skin Complications • Pressure injuries • Skin rashes or contact allergies • Wound infection • Wound dehiscence • Wound evisceration

HIV

Retrovirus that attacks CD4 T cells Damages immune system reducing CD4 T cells Is the virus that causes acquired immunodeficiency syndrome

Rhinosinusitis

Rhinosinusitis is an inflammation of the mucous membranes of one or more of the sinuses and is usually seen with rhinitis, especially the common cold (coryza). Anything that interferes with sinus drainage (e.g., deviated nasal septum, nasal polyps or tumors, inhaled air pollutants or cocaine, allergies, facial trauma, and dental infection) can lead to rhinosinusitis. Even when the problem starts with a noninfectious cause such as seasonal allergies, swelling usually blocks the flow of secretions from the sinuses, which may then become infected. Most episodes of rhinosinusitis are caused by viruses and usually develop in the maxillary and frontal sinuses, although bacterial infections also can occur. Complications include cellulitis, abscess, and meningitis. Diagnosis is made based on the patient's history and symptoms, but other tests in complicated cases include endoscopic examination and CT scans. Plain x-rays are not helpful in viewing sinuses and are not recommended. Purulent drainage, fever, and lack of response to decongestants can indicate a bacterial infection

Lung Anatomy

Right Lung (60%) -3 Lobes Left Lung (40%) -2 Lobes (has cardiac notch where heart lies) Fissures allow lobes to slide & move around thoracic cavity Reserve volume -Residual volume is volume you can't get out, recuruits other areas Pleura -Visceral (lung ) -Parietal (chest wall) Pleural Space Pleura: membrane covering the lung; allows to ventilate -creates a liquid interface -pneumothorax (air) -pleural effusion (fluid) -empyema (infection: Staphylococcus, E.coli, many others)

The Step System for Medication Use in Asthma Control

STEP 1- As-needed rapid-acting beta2agonist (relief inhaler). No daily drugs needed. STEP 2- As-needed rapid-acting beta2agonist (relief inhaler). No daily drugs needed. Daily treatment involves the use of one of these two options: Low-dose ICS, Leukotriene modifier* STEP 3- As-needed rapid-acting beta2 agonist (relief inhaler). Daily treatment involves the use of one of these four options: Low-dose ICS and long-acting beta2 agonist. Medium-dose or high-dose ICS Low-dose ICS and leukotriene modifier Low-dose ICS and sustained-release theophylline STEP 4- As-needed rapid-acting beta2 agonist (relief inhaler).Daily treatment involves the use of the Step 3 option that provided the best degree of control and was well tolerated along with one or more of these two options: Medium-dose or high-dose ICS and long-acting beta2 agonist. Leukotriene modifier and sustained-release theophylline. STEP 5: As-needed rapid-acting beta2 agonist (relief inhaler). Daily treatment involves the use of the Step 4 option(s) that provided the best degree of control and was well tolerated along with either of these two options: Oral glucocorticosteroid (lowest dose). Anti-IgE† treatment.

Meeting Healthy People 2020 Objectives: Heart Disease and Stroke

Selected objectives retained from Healthy People 2010: • Increase the proportion of adults with high blood pressure who are taking action to help control their blood pressure. • Increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high. Selected objectives retained but modified from Healthy People 2010: • Reduce the proportion of people in the population with hypertension. • Increase the proportion of adults with prehypertension who meet the recommended guidelines for: a. Body mass index (BMI) b. Saturated fat consumption c. Sodium intake d. Physical activity e. Moderate alcohol consumption • Increase the proportion of adults with hypertension who meet the [above] recommended guidelines. New objectives for Healthy People 2020: • Increase the proportion of adults with hypertension who are taking the recommended medications to decrease their blood pressure.

Contact Dermatitis(Poison Ivy/Oak, Latex)

Signs/Symptoms: (within hours of exposure) area red, itchy. Diagnosis: Detailed history, assessment of lesions. Medical Treatment: Baking soda baths, oatmeal baths, topical treatments. Nursing Care: Meds/treatments, education (no scratching, avoid contact)

Anaphylaxis

Signs/Symptoms: Respiratory distress, wheezing, hypoxia, cyanosis, hypotension, tachycardia, incontinence. Loss of consciousness, nausea, vomiting, cramping Diagnosis/Tests: History, physical assessment, symptomatic treatment. May have ABG's and/or EKG done during acute phase Medical treatment: Epinephrine administration (IV or SQ), Establish airway, Administer oxygen, Antihistamine administration, Fluid support (oral or IV) Nursing care: HOB & feet/legs ↑, education, ID bracelet/Allergy kit (Epi-pen), Administer meds, don't leave client

Allergic Rhinitis (Hay fever)

Signs/Symptoms: Sneezing, runny nose, nasal itching, facial pain, pain in temples, back of head Diagnosis: History, physical assessment, skin testing, food trials, and elimination diet Medical treatment: Avoidance allergen, antihistamines, decongestant, steroid, desensitization treatment Nursing care: Education (meds, allergen avoidance), monitoring plan of care. With allergic reactions teach patient how to practice preventive measures

Angioedema

Signs/Symptoms: Swelling area beneath the skin and mucosa; seen more in eyes, lips, hands, feet; laryngeal swelling, urticaria. Diagnosis: Based on symptoms, H&P, skin testing, or (C1-INH test) Medical Treatment: Avoid antigen, antihistamines, steroids, allergy shots. Culture Concern: African Americans: Angiotensin-converting enzyme inhibitors (ACEI's) for HTN causes angioedema in a large percentage. Use caution, educate on S/S. Nursing Care: Administering meds, evaluating response, education, Maintain Airway!

Other Indicators of Respiratory Adequacy

Skin and mucous membrane changes (e.g., pallor, cyanosis) may indicate inadequate GAS EXCHANGE and PERFUSION. Assess the nail beds and the mucous membranes of the oral cavity. Examine the fingers for clubbing, which indicates long-term hypoxia. General appearance includes muscle development and general body build. Long-term respiratory problems lead to weight loss and a loss of general muscle mass. Arms and legs may appear thin or poorly muscled. Neck and chest muscles may be hypertrophied, especially in the patient with chronic obstructive pulmonary disease (COPD) (McCance et al., 2014). Endurance decreases when breathing is inadequate for GAS EXCHANGE. Observe how easily the patient moves and whether he or she is short of breath while resting or becomes short of breath when walking 10 to 20 steps. Note how often the patient stops for breath between words while speaking. Psychosocial Assessment

disease-modifying antirheumatic drugs (DMARDs)

Slow/stop rheumatic disease progression. Modify and inhibit pathological effects and immune responses of rheumatic disease. Used mostly in early stages of disease. High incidence of drug toxicity. High risk for infection. Causes birth defects. NO alcohol. May affect retina

Wheeze

Squeaky, musical, continuous sounds associated with air rushing through narrowed airways; may be heard without a stethoscope Arise from the small airways Usually do not clear with coughing Inflammation Bronchospasm (bronchial asthma) Edema Secretions Pulmonary vessel engorgement (as in cardiac "asthma")

Cromone

Stabilizes the membranes of mast cells and prevents the release of inflammatory mediators. Purpose is to prevent asthma attack triggered by inflammation or allergens.

Stages of Peripheral Arterial Disease

Stage I: Asymptomatic • No claudication is present. • Bruit or aneurysm may be present. • Pedal pulses are decreased or absent. Stage II: Claudication • Muscle pain, cramping, or burning occurs with exercise and is relieved with rest. • Symptoms are reproducible with exercise. Stage III: Rest Pain • Pain while resting commonly awakens the patient at night. • Pain is described as numbness, burning, toothache-type pain. • Pain usually occurs in the distal part of the extremity (toes, arch, forefoot, or heel), rarely in the calf or the ankle. • Pain is relieved by placing the extremity in a dependent position. Stage IV: Necrosis/Gangrene • Ulcers and blackened tissue occur on the toes, forefoot, and heel. • Distinctive gangrenous odor is present.

endovascular stent grafts

Stents (wirelike devices) are inserted percutaneously (through the skin), avoiding abdominal incisions and therefore decreasing the risk for a prolonged postoperative recovery. Postoperative care is similar to care required after an arteriogram (angiogram). Different designs of endovascular stent grafts are used, depending on the anatomic involvement of the aneurysm. The stent graft is flexible with either Dacron or polytetrafluoroethylene (PTFE) material. It is inserted through a skin incision into the femoral artery by way of a catheter-based system. The catheter is advanced to a level above the aneurysm away from the renal arteries. The graft is released from the catheter, and the stent graft is placed with a series of hooks. This procedure is done in collaboration with the vascular surgeon, interventional radiologist, operating suite team, and, at some centers, the vascular medicine physician.

Members of the Surgical Team

Sterile team: -Surgeon and surgical assistant or RNFA -Scrub nurse -Surgical technologist Clean team: -Anesthesia providers -Circulating nurse -ORTs/surgical technologists may be used in addition to nursing staff -Holding area nurse -Specialty nurses

Supportive therapy for DVT

Supportive therapy for DVT has typically included bedrest and elevation of the extremity. However, research shows that ambulation does not increase the risk for pulmonary embolus (Lip & Hull, 2015). The risk of pulmonary embolism (PE) associated with more aggressive activity is unknown. The accepted approach is a gradual increase in ambulation as tolerated by the patient. Allowing patients to ambulate may decrease their fear and anxiety about dislodging the clot and life-threatening complications. Teach the patient to elevate his or her legs when in the bed and chair. To help prevent chronic venous insufficiency, instruct patients with active and resolving DVT to wear knee- or thigh-high sequential or graduated compression stockings for an extended period. Be sure to select the correct stocking size for the patient according to the sizing chart provided. Some health care providers prescribe intermittent or continuous warm, moist soaks to the affected area. To prevent the thrombus from dislodging and becoming an embolus, do not massage the affected extremity. Monitor all patients for signs and symptoms of PE, which include shortness of breath, chest pain, and acute confusion (in older adults).

Lung Cancer Surgical Treatment

Surgery is the main treatment for stage I and stage II NSCLC. Total tumor removal may result in a cure. If complete resection is not possible, the surgeon removes the bulk of the tumor. The specific surgery depends on the stage of the cancer and the patient's overall health. Lung cancer surgery may involve removal of the tumor only, removal of a lung segment, removal of a lobe (lobectomy), or removal of the entire lung (pneumonectomy). These procedures can be performed by open thoracotomy or by minimally invasive surgery in select patients.

Prednisone (oral drug)

Teach patient about expected side effects because knowing which side effects to expect may reduce anxiety when they appear. Teach patient to avoid anyone who has an upper respiratory infection because the drug reduces all protective inflammatory responses, increasing the risk for infection. Teach patient to avoid activities that lead to injury because blood vessels become more fragile, leading to bruising and petechiae. Teach patient to take drug with food to help reduce the side effect of GI ulceration. Teach patient not to suddenly stop taking the drug for any reason because the drug suppresses adrenal production of corticosteroids, which are essential for life.

Salmeterol (Serevent) (inhaled drug) Indacaterol (Arcapta Neohaler) (COPD only) (inhaled drug) Formoterol (Perforomist) Arformoterol (Brovana) (COPD only)

Teach patient to not use these drugs as reliever drugs because they have a slow onset of action and do not relieve acute symptoms. Teach patient the correct technique for using the MDI or DPI to ensure that the drug reaches the site of action.

Montelukast (Singulair) (oral drug)

Teach patient to use the drug daily, even when no symptoms are present, because maximum effectiveness requires continued use for 48-72 hr and depends on regular use. Teach patient not to decrease the dose of or stop taking any other asthma drugs unless instructed by the health care professional because this drug is for long-term asthma control and does not replace other drugs, especially corticosteroids and reliever (rescue) drugs.

Fluticasone (Ellipta) (MDI inhaled drug) Beclomethasone (Qvar) (MDI inhaled drug) Budesonide (Pulmicort) (MDI inhaled drug)

Teach patient to use the drug daily, even when no symptoms are present, because 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 because these drugs reduce local immunity and increase the risk for local infections, especiallyCandida albicans (yeast). Teach patient to not use these drugs as reliever drugs because they have a slow onset of action and do not relieve acute symptoms. Teach patient the correct technique for using the MDI to ensure that the drug reaches the site of action.

PCA Patient Education

Teach patients how to use the PCA device and to report side effects such as dizziness, nausea and vomiting, and excessive sedation. As with all opioids, monitor the patient's sedation level and respiratory status at least every 2 hours. Promptly decrease the opioid dose (i.e., discontinue basal rate) if increased sedation is detected.

Angiotensin II Receptor Blockers (ARBs) Nursing Implications Common examples of ARBs: • Valsartan (Diovan) • Losartan (Cozaar)

Teach patients to avoid foods high in potassium because ARBs can cause hyperkalemia, especially when combined with other hypertensive agents. Monitor BP carefully, especially orthostatic pressures, because these agents result in vasodilation and decreased BP. • Do not give the drug without checking with the health care provider if systolic BP is below 100.

Myoglobinuria

The abnormal presence of a hemoglobin-like chemical of muscle tissue in the urine; it is the result of muscle deterioration.

atherosclerosis Assessment

The assessment of a patient with atherosclerosis includes a complete cardiovascular assessment because associated heart disease is often present. Because of the high incidence of hypertension in patients with atherosclerosis, assess the blood pressure in both arms. Palpate pulses at all of the major sites on the body and note any differences. Palpate each carotid artery separately to prevent blocking blood flow to the brain! Also feel for temperature differences in the lower extremities and check capillary filling. Prolonged capillary filling (>3 seconds in young-to-middle-age adults; >5 seconds in older adults) generally indicates poor circulation, although this is not the most reliable indicator of PERFUSION. With severe atherosclerotic disease, the extremity may be cool or cold with a diminished or absent pulse.

Unfractionated Heparin Therapy

The health care provider prescribes UFH to prevent further CLOTTING, which often develops in the presence of an existing clot, and to prevent enlargement of the existing clot. Over a long period of time, the body slowly absorbs the existing clot. Before UFH administration, a baseline prothrombin time (PT), activated partial thromboplastin time (APTT or aPTT), international normalized ratio (INR), complete blood count (CBC) with platelet count, urinalysis, stool for occult blood, and creatinine level are required. Notify the primary health care provider if the platelet count is below 100,000 to 120,000/mm3, depending on agency protocol. UFH is initially given in a bolus IV dose of about 80 to 100 units/kg of body weight in a prefilled syringe or 5000 units followed by continuous infusion via an infusion pump

Lung Cancer Diagnostics

The diagnosis of lung cancer is made by examination of cancer cells. Cytologic testing of early-morning sputum specimens may identify tumor cells; however, cancer cells may not be present in the sputum. When pleural effusion is present, fluid is obtained by thoracentesis for cytology. Most commonly, lung lesions are first identified on chest x-rays. CT scans are then used to identify the lesions more clearly and guide biopsy procedures. A thoracoscopy to directly view lung tissue may be performed through a video-assisted thoracoscope entering the chest cavity via small incisions through the chest wall. Spread to mediastinal lymph nodes is assessed with a mediastinoscopy through a small chest incision. Other diagnostic studies may be needed to determine how widely the cancer has spread. Such tests include needle biopsy of lymph nodes, direct surgical biopsy, and thoracentesis with pleural biopsy. MRI and radionuclide scans of the liver, spleen, brain, and bone help determine the location of metastatic tumors. Pulmonary function tests (PFTs) and arterial blood gas (ABG) analysis help determine the overall respiratory status. Positron emission tomography (PET) scanning is becoming the most thorough way to locate metastases. These tests help determine the extent of the cancer and the best methods to treat it.

Pertussis Assessment and Treatment

The disease has three distinct phases. During the first (catarrhal) phase, the patient has symptoms resembling the common cold, including a mild cough. After 1 to 2 weeks, the paroxysmal stage begins, and the patient has severe coughing "fits" lasting several minutes. During the coughing spasms the patient may turn red and/or vomit. He or she is frequently exhausted by the coughing. The distinct "whooping" sound common in children at the end of a cough may not be present in adults. There is a bloody, purulent, thick exudate in the small airways that can lead to atelectasis and pneumonia. This stage can last up to 10 weeks. The recovery (convalescent) stage lasts for months. The diagnosis of pertussis can be made based on the patient's reported symptoms, but sputum cultures (obtained by deep suctioning) and PCR laboratory testing are also available. Blood cultures are negative.

Hierarchy of Pain Measures

The key components of the Hierarchy require the nurse to (1) attempt to obtain self-report; (2) consider underlying pathology or conditions and procedures that might be painful (e.g., surgery); (3) observe behaviors; (4) evaluate physiologic indicators; and (5) conduct an analgesic trial

NOACs/DOACs

The latest development in anticoagulation is the use of NOACs (also referred to as direct oral anticoagulants [DOACs]). These medications (dabigatran [Pradaxa], rivaroxaban [Xarelto], apixaban [Eliquis], edoxaban [Savaysa]) were developed to have fewer drug interactions and a wide therapeutic index to allow for fixed dosing without the need for frequent laboratory monitoring. DO NOT STOP TAKING ABRUPTLY. Antidote: The FDA has approved the use of idarucizumab (Praxbind) as an antidote or reversal agent for dabigatran. Idarucizumab binds to dabigatran, which prevents dabigatran from inhibiting thrombin. Side effects of idarucizumab include hypokalemia, confusion, constipation, fever, and pneumonia. Use of idarucizumab increases the risk of CLOTTING and should only be used in the event of life-threatening bleeding.

Adverse Effects of Opioid Analgesics

The most common side effects of opioid analgesics are constipation, nausea, vomiting, pruritus, and sedation. Respiratory depression is less common but the most feared of the opioid side effects. Most of the opioid side effects are dose related; therefore simply decreasing the opioid dose is sufficient to eliminate or make the most of the side effects tolerable for most patients.

Improving Gas Exchange Planning: Expected Outcomes.

The patient is expected to attain and maintain optimal lung expansion and breathing patterns after surgery as indicated by: • Partial pressure of arterial oxygen (Pao2) within normal range • Partial pressure of arterial carbon dioxide (Paco2) within normal range • Oxygen saturation values within normal range

Pulmonary Circulation

The passage of venous blood from the right atrium of the heart through the right ventricle and pulmonary arteries to the lungs where it is oxygenated and its return via the pulmonary veins to enter the left atrium and participate in systemic circulation.

Rib Fracture

The patient has pain on movement and splints the chest defensively. Splinting reduces breathing depth and clearance of secretions. If the patient has pre-existing lung disease, the risk for atelectasis and pneumonia increases. Those with injuries to the first or second ribs, flail chest, seven or more fractured ribs, or expired volumes of less than 15 mL/kg often have a deep chest injury and a poor prognosis. Management of uncomplicated rib fractures is simple because the fractured ribs reunite spontaneously. The chest is usually not splinted by tape or other materials. The main focus is to decrease pain so adequate GAS EXCHANGE is maintained. An intercostal nerve block may be used if pain is severe. Analgesics that cause respiratory depression are avoided.

Cryptosporidiosis

a diarrheal disease caused by an intestinal infection , which is spread by contact with fecally contaminated water. Loss of appetite and severe weight loss. Treated with antiretrovirals and antimicrobials. no cure. wasting syndrome

Tuberculosis Assessment

The patient with TB has progressive fatigue, lethargy, nausea, anorexia, weight loss, irregular menses, and a low-grade fever. Symptoms 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 symptoms to help with diagnosis, establish a baseline, and plan nursing interventions. When assessing the patient, you may note dullness with percussion over the involved lung fields, 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.

Flail Chest

The patient with a flail chest may be managed with vigilant respiratory care. Mechanical ventilation is needed if respiratory failure or shock occurs. Monitor ABG values and vital capacity closely. With severe hypoxemia and hypercarbia, the patient is intubated and mechanically ventilated with PEEP. With lung contusion or an underlying pulmonary disease, the risk for respiratory failure increases. Usually flail chest is stabilized by positive-pressure ventilation. Surgical stabilization is used only in extreme cases of flail chest (Messing et al., 2014). Monitor the patient's vital signs and fluid and electrolyte balance closely so hypovolemia or shock can be managed immediately. If he or she has a lung contusion, provide oxygen as needed and give IV fluids as prescribed. Assess for and relieve pain with prescribed analgesic drugs by IV, epidural, or nerve block route. Give psychosocial support to the anxious patient by explaining all procedures, talking slowly, and allowing time for expression of feelings and concerns.

Asthma History Assessment

The patient with asthma usually has a pattern of intermittent episodes of dyspnea (shortness of breath), chest tightness, coughing, wheezing, and increased mucus production. Ask whether the symptoms occur continuously, seasonally, in association with specific activities or exposures, at work, or more frequently at night. Some patients have symptoms for 4 to 8 weeks after a cold or other upper respiratory infection. The patient with atopic (allergic) asthma also may have other allergic problems. Ask whether any family members have asthma or respiratory problems. Ask about current or previous smoking habits. If the patient smokes, use this opportunity to teach him or her about smoking cessation

Seasonal Influenza

The patient with influenza often has a rapid onset of severe headache, muscle aches, fever, chills, fatigue, and weakness. Adults are contagious from 24 hours before symptoms occur and up to 5 days after they begin. Sore throat, cough, and watery nasal discharge can also occur. Infection with influenza strain B can lead to nausea, vomiting, and diarrhea. Most patients feel fatigued for 1 to 2 weeks after the acute episode has resolved. Vaccinations for the prevention of influenza are widely available and are recommended for adults by The Joint Commission's National Patient Safety Goals (NPSGs). Antiviral agents such as oseltamivir (Tamiflu), zanamivir (Relenza), and peramivir (Rapivab) have been effective in the prevention and treatment of some strains of influenza A and B.

Peri-Op Nurse Role in Consent

The perioperative nurse is not responsible for providing detailed information about the surgical procedure. The nurse's 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. The nurse must verify that the consent form is signed, and he or she may serve as a witness to the signature, not to the fact that the patient is informed

communicable disease

a disease that is spread from one host to another

VTE Other Diagnostic Assessments

The preferred diagnostic test for DVT is venous duplex ultrasonography, a noninvasive ultrasound that assesses the flow of blood through the veins of the arms and legs. Doppler flow studies may also be useful in the diagnosis, but they are more sensitive in detecting proximal rather than distal DVT. Impedance plethysmography assesses venous outflow and can detect most DVTs that are located above the popliteal vein. Magnetic resonance direct thrombus imaging (MRI), another noninvasive test, is useful in finding a DVT in the proximal deep veins and is better than traditional venography in finding DVT in the inferior vena cava or pelvic veins. A D-dimer test is a global marker of coagulation activation and measures fibrin degradation products produced from fibrinolysis (clot breakdown). The test is used for the diagnosis of DVT when the patient has few clinical signs and stratifies patients into a high-risk category for recurrence.

Which bronchus is more likely to be entered if a patient aspirates?

The right side since it is more vertical. This can be prevented by eating a puree diet, sitting up to eat, and thickened liquids.

Lung Biopsy

The samples are used to make a definite diagnosis of inflammation, cancer, infection, or lung disease. There are several types of lung biopsies. The site and extent of the lesion determine which one is used. Transbronchial biopsy (TBB) and transbronchial needle aspiration (TBNA) are performed during bronchoscopy. Transthoracic needle aspiration is performed through the skin (percutaneous) for areas that cannot be reached by bronchoscopy. Monitor the patient's vital signs and breath sounds at least every 4 hours for 24 hours and assess for signs of respiratory distress (e.g., dyspnea, pallor, diaphoresis, tachypnea). Pneumothorax is a serious complication of needle biopsy and open-lung biopsy. Report reduced or absent breath sounds immediately. Monitor for hemoptysis (which may be scant and transient) or, in rare cases, for frank bleeding from vascular or lung trauma.

Post op Dressing Assessment

The surgeon usually performs the first dressing change to assess the wound, remove any packing, and advance (pull partially out) or remove drains. Before the first dressing change, reinforce the dressing (add more dressing material to the existing dressing) if it becomes wet from drainage. Document the added material and the color, type, amount, and odor of drainage fluid and time of observation. Assess the surgical site at least every shift and report any unexpected findings to the surgeon.

Drug Formulation Terminology

The terms modified release, extended release (ER), sustained release (SR), and controlled release (CR) are used to describe opioids that are formulated to release over a prolonged period of time. For the purposes of this chapter, the term modified release will be used when discussing these opioid formulations. Long acting is applied to drugs with a long half-life such as methadone. The half-life of a drug provides an estimate of how fast the drug leaves the body. By definition, half-life is the time it takes for the amount of drug in the body to be reduced by 50%

NPPV modes of delivery

The three most common modes of delivery for NPPV are (1) continuous positive airway pressure (CPAP), which delivers a set positive airway pressure throughout each cycle of inhalation and exhalation; (2) volume-limited or flow-limited, which delivers a set tidal volume with the patient's inspiratory effort; and (3) pressure-limited, which includes pressure support, pressure control, and bi-level positive airway pressure (BiPAP), which cycles different pressures at inspiration and expiration. For BiPAP, a cycling machine delivers a set inspiratory positive airway pressure each time the patient begins to inspire. As he or she begins to exhale, the machine delivers a lower set end-expiratory pressure. Together, these two pressures improve tidal volume, can reduce respiratory rate, and may relieve dyspnea. For CPAP the effect is to open collapsed alveoli. Patients who may benefit from this form of oxygen or air delivery include those with atelectasis after surgery or cardiac-induced pulmonary edema or those with COPD. It is not helpful for patients with respiratory failure following extubation. However, both CPAP and BiPAP are used after extubation to prevent respiratory failure and the need for re-intubation. NPPV is used in palliative care to relieve dyspnea, including for those patients with "do-not-intubate" orders. However, this practice is controversial. The Society of Critical Care Medicine recommends discussing goals and expected outcomes with the patient and family before initiating therapy. NPPV is used for sleep apnea.

The tuberculin Test

The tuberculin test (Mantoux test) is the most commonly used reliable screening test for TB. A small amount (0.1 mL) of purified protein derivative (PPD) is placed intradermally in the forearm. The test is "read" in 48 to 72 hours. An area of induration (localized swelling with hardness of soft tissue), not just redness, measuring 10 mm or greater in diameter, indicates exposure to and possible infection with TB. In certain adults, such as those with decreased IMMUNITY, induration of 5 mm is a positive result. If possible, the site is re-evaluated after 72 hours because false-negative readings occur more often after only 48 hours (CDC, 2015l). A positive reaction indicates exposure to TB or the presence of inactive (dormant) disease, not active disease. A reduced skin reaction or a negative skin test does not rule out TB disease or infection of the very old or anyone who has severely reduced IMMUNITY. Failure to have a skin response because of reduced immunity when infection is present is called anergy.

emphysema

The two major changes that occur with emphysema are loss of lung elasticity and hyperinflation of the lung. These changes result in dyspnea, reduced GAS EXCHANGE, and the need for an increased respiratory rate. 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.

Oxygen Delivery Systems

The type of delivery system used depends on: • Oxygen concentration required by the patient • Oxygen concentration achieved by a delivery system • Importance of accuracy and control of the oxygen concentration • Patient comfort • Importance of humidity • Patient mobility

Cystic Fibrosis

The underlying problem of CF is blocked chloride transport in the cell membranes. Poor chloride transport causes the formation of mucus that has little water content and is thick. The thick, sticky mucus causes problems in the lungs, pancreas, liver, salivary glands, and testes. The mucus plugs up the airways in the lungs and the glandular tissues in nonpulmonary organs, causing atrophy and organ dysfunction. Nonpulmonary problems include pancreatic insufficiency, malnutrition, intestinal obstruction, poor growth, male sterility, and cirrhosis of the liver. Additional problems of CF in young adults include osteoporosis and diabetes mellitus. Respiratory failure is the main cause of death. The pulmonary problems of CF result from the constant presence of thick, sticky mucus and are the most serious complications of the disease. The mucus narrows airways, reducing airflow and interfering with GAS EXCHANGE. The constant presence of mucus results in chronic respiratory tract infections, chronic bronchitis, and dilation of the bronchioles (bronchiectasis). Lung abscesses are common. Over time, the bronchioles distend, and mucus-producing cells have increased numbers (hyperplasia) and increased size (hypertrophy). Complications include pneumothorax, arterial erosion and hemorrhage, and respiratory failure.

Post Op Drug Therapy

The use of opioids or other analgesics for pain management may mask or increase the severity of symptoms of an anesthesia reaction. Therefore give these drugs with caution, especially in the PACU when the patient's condition is not stable. In the PACU pain drugs are usually given IV in small doses. After receiving any drug for pain, the patient remains in the PACU for a defined period (often 45 to 60 minutes). Assess for hypotension, respiratory depression, and other side effects. Within 5 to 10 minutes after an IV pain drug is given, assess the effectiveness of the drug (i.e., on a rating scale) in relieving pain and document the patient's response. Opioid analgesics are given during the first 24 to 48 hours after surgery to control acute pain. Around-the-clock scheduling or the use of patient-controlled analgesia (PCA) systems is more effective and allows consistent blood levels more than does "on demand" scheduling. Common drugs include morphine (Statex ), hydromorphone (Dilaudid; Hydromorph Contin ; Jurnista ), ketorolac (Toradol), codeine, butorphanol (Stadol), and oxycodone with aspirin (Percodan) or oxycodone with acetaminophen (Percocet).

percutaneous vascular intervention

This procedure requires an arterial puncture in the patient's groin. One or more arteries are dilated with a balloon catheter advanced through a cannula, which is inserted into or above an occluded or stenosed artery. When the procedure is successful, it opens the vessel and improves arterial blood flow. Patients who are candidates for percutaneous procedures must have occlusions or stenoses that are accessible to the catheter. Reocclusion may occur, and the procedure may be repeated. Some patients are occlusion-free for up to 3 to 5 years, whereas others may experience reocclusion within a year.

Idiopathic Pulmonary Fibrosis: Treatment

Therapy focuses on slowing the fibrotic process and managing dyspnea. Corticosteroids and other immunosuppressants are the mainstays of therapy. Immunosuppressant drugs include cytotoxic drugs such as cyclophosphamide (Cytoxan, Neosar, Procytox ), azathioprine (Imuran), chlorambucil (Leukeran), or methotrexate (Folex). These drugs have many side effects, including increased infection risk, nausea, and lung and liver damage and have shown limited benefit. Studies using the combination therapy of corticosteroids, azathiaprine, interferon gamma 1b, and N-acetylcysteine show promise of slowing disease progression. Newer approved drugs include nintedanib (Ofev), a tyrosine kinase inhibitor, and pirfenidone (Esbriet), an antifibrotic agent. Home oxygen is needed by the time the patient has dyspnea because significant fibrosis has already occurred and GAS EXCHANGE is reduced. Lung transplantation is a curative therapy; however, the selection criteria, cost, and availability of organs make this option unlikely for most patients. In the later stages of the disease, the focus is to reduce the sensation of dyspnea. This is often accomplished with the use of oral, parenteral, or nebulized morphine. Provide information about hospice, which supports and coordinates resources to meet the needs of the patient and family when the prognosis for survival is less than 6 months

Diuretics

Thiazide diuretics: Hydrochlorothiazide = HCTZ Loop diuretics: Furosemide Bumetanide Torsemide Potassium-sparing diuretics: Spironolactone Triamterene Amiloride

Thoracic Aneurysm

Thoracic aortic aneurysms (TAAs) are not quite as common and are frequently misdiagnosed. They are typically discovered when advanced imaging is used to assess other conditions. TAAs commonly develop between the origin of the left subclavian artery and the diaphragm. They are located in the descending, ascending, and transverse sections of the aorta. They can also occur in the aortic arch and are very difficult to manage surgically.

Peripheral Venous Disease

Three health problems alter the blood flow in veins: • Thrombus formation (venous thrombosis) can lead to pulmonary embolism (PE), a life-threatening complication. Venous thromboembolism (VTE) is the current term that includes both deep vein thrombosis and PE. • Defective valves lead to venous insufficiency and varicose veins, which are not life threatening but are problematic. • Skeletal muscles do not contract to help pump blood in the veins. This problem can occur when weight bearing is limited or muscle tone decreases.

Venous Thromboembolism Etiology

Thrombus formation has been associated with stasis of blood flow, endothelial injury, and/or hypercoagulability, known as Virchow's triad. The precise cause of these events remains unknown; however, a few predisposing factors have been identified. The highest incidence of clot formation occurs in patients who have undergone hip surgery, total knee replacement, or open prostate surgery. Other conditions that seem to promote thrombus formation are ulcerative colitis, heart failure, cancer, oral contraceptives, and immobility. Complications of immobility occur during prolonged bedrest such as when a patient is confined to bed for an extensive illness. People who sit for long periods (e.g., on an airplane or at a computer) are also at risk. Phlebitis (vein inflammation) associated with invasive procedures such as IV therapy can also predispose patients to thrombosis.

General Immunity: Mast Cells & Compliment

Tissue Mast Cells: 1% NOT a WBC Function: defends parasite infections, maintain and prolongs inflammation and allergic reactions Compliment System- plasma proteins coats target, catalyst reaction. lives in connective tissue at the mucosal surface of the body, stimulated by a WBC

Care Issues for the Patient With a Tracheostomy: Ensuring Air Warming and Humidification

To prevent these complications, humidify the air as prescribed. Continually assess for a fine mist emerging from the tracheostomy collar or T-piece during ventilation. To increase the amount of humidity delivered, a warming device can be attached to the water source with a temperature probe in the tubing circuit. Monitor the circuit temperature hourly by feeling the tubing and by checking the probe. Ensure adequate hydration, which also helps liquefy secretions. Increasing the flow rate at the flow meter increases the amount of delivered humidity

Aneurysms of the Peripheral Arteries ASSESSMENT

To detect a popliteal aneurysm, assess for a pulsating mass in the popliteal space. To detect a femoral aneurysm, observe a pulsatile mass over the femoral artery. To prevent its rupture, do not palpate the mass! Evaluate both extremities because more than one femoral or popliteal aneurysm may be present. The patient may have symptoms of limb ischemia (decreased PERFUSION), including diminished or absent pulses, cool to cold skin, and pain. Alterations in comfort may be present if an adjacent nerve is compressed. The recommended treatment for either type of aneurysm, regardless of size, is surgery because of the risk for thromboembolic complications.

ambulatory surgery center

a facility where minor surgery is performed and the patient does not stay overnight

Complications of Tracheostomy

Tracheomalacia Tracheal stenosis Tracheoesophageal fistula (TEF) Trachea—innominate artery fistula Tube obstruction Tube dislodgment and accidental decannulation Pneumothorax Subcutaneous emphysema Bleeding Infection

Tracheostomy

Tracheotomy is the surgical incision into the trachea to create an airway to help maintain GAS EXCHANGE. Tracheostomy is the tracheal stoma (opening) that results from the tracheotomy. A tracheotomy can be an emergency procedure or a scheduled surgery. Tracheostomies can be temporary or permanent. Indications for tracheostomy include acute airway obstruction, the need for airway protection, laryngeal or facial trauma or burns, and airway involvement during head or neck surgery. They also are used for prolonged unconsciousness, paralysis, or the inability to be weaned from mechanical ventilation. With temporary tracheostomies, the nurse is key in evaluating patient readiness for progression toward decannulation (removal of the tracheostomy tube)

Transtracheal Oxygen Therapy

Transtracheal oxygen (TTO) is a long-term method of delivering oxygen directly into the lungs. A small, flexible catheter is passed into the trachea through a small incision with the patient under local anesthesia. TTO avoids damage to TISSUE INTEGRITY from nasal prongs and is less visible. A TTO team provides patient education, including the purpose of TTO and care of the catheter. Different flow rates are prescribed for rest and activity. A flow rate also is prescribed for the nasal cannula, which is used when the TTO catheter is being cleaned.

Traveling r/t Respiratory System

Travel and geographic area of residence may reveal exposure to certain diseases. For example, histoplasmosis, a fungal disease caused by inhalation of contaminated dust, is found in the central parts of the United States and Canada. Coccidioidomycosis is found in the western and southwestern parts of the United States, in Mexico, and in parts of Central America, as is Hantavirus. With veterans, ask about location of deployments within the past year. Family History and Genetic Risk

Tracheostomy Tube dislodgment

Tube dislodgment and accidental decannulation can occur when the tube is not secure. Prevent this problem by securing the tube in place to reduce movement and traction or accidental pulling by the patient. Tube dislodgment in the first 72 hours after surgery is an emergency because the tracheostomy tract has not matured and replacement is difficult. The tube may end up in the subcutaneous tissue instead of in the trachea (also referred to as "false passage"). The patient will not be able to be ventilated. Obese patients or those with short, large necks may be particularly difficult to recannulate if the tracheostomy tube is dislodged

Tracheostomy tube obstruction

Tube obstruction can occur as a result of secretions or by cuff displacement. Indicators are difficulty breathing; noisy respirations; difficulty inserting a suction catheter; thick, dry secretions; and high peak pressures (if a mechanical ventilator is used). Assess the patient at least hourly for tube patency. Prevent obstruction by helping the patient cough and deep breathe, providing inner cannula care, humidifying oxygen, and suctioning. If tube obstruction results from cuff prolapse over the end of the tube, the primary health care provider repositions or replaces the tube.

Treatment of Venous Insufficiency with Ulcers

Two types of occlusive dressings are used for venous stasis ulcers: oxygen-permeable dressings and oxygen-impermeable dressings. If the patient is ambulatory, an Unna boot may be used. An Unna boot dressing is constructed of gauze that has been moistened with zinc oxide. The primary health care provider may prescribe topical agents, such as Accuzyme, to chemically débride the ulcer, eliminating necrotic tissue and promoting healing. Surgery for chronic venous insufficiency is not usually performed because it is not successful. Attempts at transplanting vein valves have had limited success. Surgical débridement of venous ulcers is similar to that performed for arterial ulcers.

heparin-induced thrombocytopenia (HIT)

UFH can also decrease platelet counts. Mild reductions are common and are resolved with continued heparin therapy. Severe platelet reductions, although rare, result from the development of antiplatelet bodies within 6 to 14 days after the beginning of treatment. Platelets aggregate into "white clots" that can cause thrombosis, usually in the form of an acute arterial occlusion. The health care provider discontinues heparin administration if severe heparin-induced thrombocytopenia (HIT) (platelet count <150,000), or "white clot syndrome," occurs.

Can you place pillows under the knees?

Unless pillow support is ordered, do not place pillows under the knees and do not raise the knee gatch because this position could restrict circulation and increase the risk for venous thromboembolism.

Naloxone Administration

Unless the patient is at the end of life, promptly administer the opioid antagonist naloxone (Narcan) IV to reverse clinically significant opioid-induced respiratory depression, usually when the respiratory rate is less than 8 breaths per minute or according to agency protocol. When giving the opioid antagonist naloxone, administer it slowly until the patient is more arousable and respirations increase to an acceptable rate. The desired outcome is to reverse just the sedative and respiratory depressant effects of the opioid but not the analgesic effects. Giving too much naloxone too fast not only can cause severe pain but also can lead to ventricular dysrhythmias, pulmonary edema, and even death. Continue to closely monitor the patient after giving naloxone because its duration is shorter than that of most opioids and respiratory depression can recur. Sometimes more than one dose of naloxone is needed.

Upper Airway Obstruction

Upper airway obstruction is the interruption of airflow through nose, mouth, pharynx, or larynx. When GAS EXCHANGE is impaired, obstruction can be a life-threatening condition. Early recognition is essential to prevent complications, including respiratory arrest

Post op urine output

Urine output should be close to the total intake for a 24-hour period. Consider sweat, vomitus, or diarrhea stools as sources of fluid 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

Circulating Nurse

Uses clinical decision-making skills to develop a plan of care and coordinates care delivery to patients and their family members; coordinates, oversees, and implements nursing care interventions to support the patient during the surgical procedure Sets up the operating room, gathers supplies, anticipates equipment needed, and inspects all equipment for safety and functionality; prepares positioning devices and ensures that the physical environment is clean and at the proper temperature for the patient's arrival Throughout the surgery the circulating nurse: • Protects the patient's privacy • Ensures the patient's safety • Monitors traffic in the room • Assess urinary output and blood loss • Communicates finding to surgeon and anesthesiologist • Monitors sterile field and provides sterile supplies and medications to the sterile field • Anticipates the patient's and surgical team's needs • Communicates patient's status to family member(s) per protocol • Documents care, events, interventions, and findings

Venous Thromboembolism (VTE) Core Measure Set

VTE-1: VTE Prophylaxis: Number of patients who received VTE prophylaxis or have documented why no VTE prophylaxis was given the day of or the day after hospital admission or surgery VTE-2: ICU VTE: Number of patients who received VTE prophylaxis on ICU admission or have documented why no VTE prophylaxis was given the day of admission, transfer, or surgery VTE-3: VTE Patients With Anticoagulant Overlap Therapy: Number of patients diagnosed with confirmed VTE who received overlap of parenteral anticoagulant and warfarin VTE-4: VTE Patients Receiving Unfractionated Heparin: Number of patients receiving heparin with dosages/platelet count monitoring by protocol or nomogram VTE-5: VTE Warfarin Therapy Discharge Instructions: Number of patients who received written instructions that address these four criteria: • Compliance issues • Dietary advice • Follow-up monitoring • Information about potential for adverse drug reactions/interactions VTE-6: Hospital-Acquired Potentially Preventable VTE: Number of patients who developed VTE while hospitalized

Venous Insufficiency Assessment

Venous insufficiency may result in edema of both legs. There may be stasis dermatitis or reddish-brown discoloration along the ankles, extending up to the calf. In people with long-term venous insufficiency, stasis ulcers often form. They can result from the edema or from minor injury to the limb. Ulcers typically occur over the malleolus, more often medially (inner ankle) than laterally (outer ankle). The ulcer usually has irregular borders.

Post-Op Circulation Assessment

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. Decreased blood pressure, 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, or prolonged exposure to the cool environment of the OR suite (Touhy & Jett, 2015). An increased pulse rate could indicate hemorrhage, shock, or pain.

Oral anticoagulants

Warfarin: prevents clotting monitor labs monitor for improvement or worsening of symptoms Antidote: Vitamin K

Nursing Implications: Rifampin (RIF, Rifadin, Rimactane, Rofact ) Kills slower-growing organisms, even those that reside inside macrophages and caseating granulomas

Warn patients to expect an orange-reddish staining of the skin and urine, and all other secretions to have a reddish-orange tinge; also, soft contact lenses will become permanently stained because knowing the expected side effects decreases anxiety when they appear. Instruct sexually active women using oral contraceptives to use an additional method of contraception while taking this drug and for 1 month after stopping it because this drug reduces the effectiveness of oral contraceptives. Remind the patient to avoid drinking alcoholic beverages while on this drug because the liver-damaging effects of this drug are potentiated by drinking alcohol. Tell 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, which are signs and symptoms of liver toxicity or failure. Ask the patient about all other drugs in use because this drug interacts with many other drugs.

Sedation Critical Rescue intervention

Watch the rise and fall of the patient's chest to determine depth and regularity of respirations in addition to counting the respiratory rate for 60 seconds. For accuracy, respiratory assessment is done before arousing the sleeping patient. If a patient is difficult to arouse, always stop the opioid, stay with the patient, continue vigorous attempts to arouse, and call for help! Listening to the sound of the patient's respiration is critical as well—snoring indicates airway obstruction and must be attended to promptly with repositioning, including placing the patient in a sitting position. Depending on severity, collaborate with the respiratory therapist for consultation and further evaluation.

Thoracic Aneurysm S/S

When a thoracic aortic aneurysm is suspected, assess for back pain and manifestations of compression of the aneurysm on adjacent structures. Signs include shortness of breath, hoarseness, and difficulty swallowing. TAAs are not often detected by physical assessment, but occasionally a mass may be visible above the suprasternal notch. Assess the patient with suspected rupture of a thoracic aneurysm for sudden and excruciating back or chest pain. Hypovolemic shock also occurs with TAA.

Post-Op Respiratory Assessment

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 reliable indicator of adequate GAS EXCHANGE. An artificial airway such as an endotracheal tube (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). The SpO2 should be above 95% (or at the patient's presurgery baseline). 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 (Ramly et al., 2015). Obese patients are also at high risk for respiratory complications.

How to Use an Inhaler Correctly

With a Spacer (Preferred Technique) 1. Before each use, remove the caps from the inhaler and the spacer. 2. Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer. 3. Shake the whole unit vigorously three or four times. 4. Fully exhale and then place the mouthpiece into your mouth, over your tongue, and seal your lips tightly around it. 5. Press down firmly on the canister of the inhaler to release one dose of medication into the spacer. 6. Breathe in slowly and deeply. If the spacer makes a whistling sound, you are breathing in too rapidly. 7. Remove the mouthpiece from your mouth; and, keeping your lips closed, hold your breath for at least 10 seconds and then breathe out slowly. 8. Wait at least 1 minute between puffs. 9. Replace the caps on the inhaler and the spacer. 10. At least once a day, clean the plastic case and cap of the inhaler by thoroughly rinsing in warm, running tap water; at least once a week, clean the spacer in the same manner. Without a Spacer 1. Before each use, remove the cap and shake the inhaler according to the instructions in the package insert. 2. Tilt your head back slightly and breathe out fully. 3. Open your mouth and place the mouthpiece 1 to 2 inches away. 4. As you begin to breathe in deeply through your mouth, press down firmly on the canister of the inhaler to release one dose of medication. 5. Continue to breathe in slowly and deeply (usually over 5-7 sec). 6. Hold your breath for at least 10 seconds to allow the medication to reach deep into the lungs and then breathe out slowly. 7. Wait at least 1 minute between puffs. 8. Replace the cap on the inhaler. 9. At least once a day, remove the canister and clean the plastic case and cap of the inhaler by thoroughly rinsing in warm, running tap water. 10. Avoid spraying in the direction of the eyes.

Impaired Wound Healing

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). Evisceration is a surgical emergency; the surgeon is contacted immediately, and the patient returned to the OR. Both dehiscence and evisceration 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 in those who are using steroids. Dehiscence or evisceration may follow forceful coughing, vomiting, or straining and not splinting the surgical site during movement. The patient may state, "Something popped" or "I feel as if I just split open."

aneurysm

a permanent localized dilation of an artery, which enlarges the artery to at least two times its normal diameter. t may be described as fusiform (a diffuse dilation affecting the entire circumference of the artery) or saccular (an outpouching affecting only a distinct portion of the artery). Aneurysms may also be described as true or false. In true aneurysms, the arterial wall is weakened by congenital or acquired problems. False aneurysms occur as a result of vessel injury or trauma to all three layers of the arterial wall. Dissecting aneurysms differ from aneurysms in that they are formed when blood accumulates in the wall of an artery.

Surgical Scrub

a procedure that achieves disinfection of the hands and arms up to the elbows in preparation for donning sterile attire and performing or participating in a sterile procedure. 3-5 min

septic shock

a serious condition that occurs when an overwhelming bacterial infection affects the body

Thromboectomy

a surgical procedure for clot removal. Preoperative and postoperative care of patients undergoing thrombectomy is similar to the care for those undergoing arterial surgery. For patients with recurrent deep vein thrombosis (DVT) or pulmonary emboli that do not respond to medical treatment and for patients who cannot tolerate anticoagulation, inferior vena cava filtration may be indicated. The surgeon or interventional radiologist inserts a filter device into the femoral vein or jugular vein. The device is meant to trap emboli in the inferior vena cava before they progress to the lungs. Holes in the device allow blood to pass through, without interfering with the return of blood to the heart. Several new filter brands are available that are designed for removal if and when DVT risks diminish. Preoperative care is similar to that provided for patients receiving local anesthesia. If they have recently been taking anticoagulants, collaborate with the health care provider about interrupting this therapy in the preoperative period to avoid hemorrhage. After surgery, inspect the groin insertion site for bleeding and signs or symptoms of infection. Other postoperative nursing care is similar to that for any patient undergoing local anesthesia

What is "white coat" hypertension?

a syndrome whereby a patient's feeling of anxiety in a medical environment results in an abnormally high reading when their blood pressure is measured.

epidemic

a widespread occurrence of an infectious disease in a community at a particular time.

pallative surgery

alleviate pain or disease symptoms. Colostomy Nerve root resection Tumor debulking Ileostomy

arteriosclerosis

abnormal hardening of the walls of an artery or arteries

Chemistry: ACID

acids are substances that release Hydrogen when dissolved in water. They increase the amount of free hydrogen in that solution. Strength is measures by hoe easily is released hydrogen in that solution

Perinatal Transmission of HIV

across the placenta during pregnancy infant exposure at birth exposure through breast milk

lymphoid stem cell

act slowly to identify and kill antigen

Metabolic Acidosis: Causes

actual: over production of acids, under elimination of acids relative: Underproduction of HCO3, over elimination of HCO3

Certified Registered Nurse Anesthetist (CRNA)

administers anesthetic agents under the supervision of physician (either anesthesiologist or surgeon) Provides fluids and blood products as needed; medications for anesthesia, analgesia, and blocks; monitors patient during surgery by assessing: • Level of anesthesia (using a peripheral nerve stimulator) • Cardiopulmonary function (electrocardiographic [ECG] monitoring) • Capnography (monitors ventilation for nonintubated patients) • Vital signs • Intake and output

Targeted Agents for Non-Small Cell Lung Cancer (NSCLC)

afatinib (Gilotrif) Oral First-line therapy for metastatic NSCLC that is positive for a mutation in the EGFR gene of either exon 19 deletion or exon 21 L858R substitution mutations alectinib (Alcensa) Oral Second-line therapy for metastatic NSCLC that has progressed after initial treatment and is ALK-positive bevacizumab (Avastin) IV First-line treatment of unresectable, locally advanced, recurrent, or metastatic nonsquamous NSCLC in combination with carboplatin and paclitaxel crizotinib (Xalkori) Oral First-line treatment of metastatic NSCLC that is ALK-positive erlotinib (Tarceva) Oral First-line treatment of metastatic NSCLC with EGFR exon 19 deletions or exon 21 (L858R) substitution mutations necitamumab (Portrazza) IV First-line treatment of metastatic squamous NSCLC in combination with gemcitabine and cisplatin nivolumab (Opdivo) IV Second-line treatment of metastatic NSCLC, with progression on or after platinum-based chemotherapy and after progression on EGFR- or ALK-targeted therapy ramucirumab (Cyramza) IV Second-line treatment of metastatic NSCLC in combination with docetaxel, with disease progression on or after platinum-based chemotherapy

anesthesia and surgery risk factors

age physical condition past medical/surgical hx nutrition smoker/substance abuser

Essential Hypertension Risk Factors

age, ethnicity, inactive or sedentary lifestyle, smoking, high salt intake, health problems, alcohol, high stress level, obesity

Acidosis Assessment

age, meds, diet, chronic problems, fatigue, confusion, anxiety, tachycardia, hyperkalemia, CNS depression, lethargy, reduced muscle tone, increased DTR

Patient-Controlled Analgesia

an interactive method of management that allows patients to treat their pain by self-administering doses of analgesics. It is used to manage all types of pain and given by multiple routes of administration, including IV, subcutaneous, epidural, and perineural. A PCA infusion device ("pump") is used when PCA is delivered by invasive routes of administration and is programmed so the patient can press a button ("pendant") to self-administer a set dose of analgesic ("PCA dose") at a set time interval ("demand" or "lockout") as needed. Patients who use PCA must be able to understand the relationships among pain, pressing the PCA button and taking the analgesic, and pain relief. They must also be cognitively and physically able to use any equipment that is used to administer the therapy.

AIDS Dementia Complex and HIV Encephalopathy Treatment

antiretroviral safety issues home care SNF symptoms range mild to severe with impairment of daily living and independence

Preventing HIV infection: Drug Therapy

antiretrovirals (cART) NRTIs NNRTIs Pis Integrase Inhibitors Fusion inhibitors entry inhibitors *look at side effects*

rheumatic diseases

any disease or condition affecting the musculoskeletal system including joints and connective tissue. most are autoimmune primary focus is connective tissue disease which is chronic

Cytotoxic T cells

attack self cells that are infected by parasites, viruses, protozoa

Arthritis

autoimmune disease that attacks tissues near joints and other body parts causing inflammation of one or more joints clinically categorized as inflammatory and non inflammatory rheumatoid is inflammatory; osteoarthritis is non inflammatory

systemic lupus erythematosus (SLE)

autoimmune disease, widespread inflammation, tissue and organ damage, joints, skin, brain, lungs, kidneys, and blood vessels. no cure onset: 20-40 yrs old lupus nephritis is the leading cause of death from lupus complications

fibromyalgia treatment

avoid stress and extreme weather limit caffeine and alcohol Gabapentin and other antiepileptics

Neuropathic Pain

believed to be sustained by a set of mechanisms driven by damage to or dysfunction of the PNS and/or CNS. In contrast to nociceptive pain, which is sustained by ongoing activation of essentially normal neural systems, neuropathic pain is sustained by the abnormal processing of stimuli. Whereas nociceptive pain involves tissue damage or inflammation, neuropathic pain may occur in the absence of either.

RA joint involvement

bilateral if one joint is hurting and the other isn't it is possible an infection is indicated proximal PIP and metatarsal MCP form nodules

What race is at greatest risk for HTN?

black patients

Hypernatremia Assessment

body is trying to hold onto water to dilute sodium.. edema, muscle twitching/cramping, confusion, restless, irritable, agitates, increased DTR, bounding pulse, crackles, decreased urine output

tracheostomy self care

by the time of discharge, the patient should be able to provide self-care, including tracheostomy care, nutrition care, suctioning, and communication. Although education begins before surgery, most self-care is taught in the hospital. Teach the patient and caregiver how to care for the tracheostomy tube. Review airway care, including cleaning and signs of infection or loss of TISSUE INTEGRITY. Teach clean suction technique and review the plan of care. Instruct the patient to use a shower shield over the tracheostomy tube when bathing to prevent water from entering the airway. Teach him or her to cover the airway loosely with a small cotton cloth to protect it during the day. Covering the opening filters the air entering the stoma, keeps humidity in the airway, and enhances appearance. Attractive coverings are available as cotton scarves, decorative collars, and jewelry. Teach the patient to increase humidity in the home. Tell him or her to wear a medical alert bracelet that identifies the inability to speak.

General Anesthesia Administration

can be delivered intravenously or through inhalation or balanced through both. There are also adjuncts to GA such as versed.

Total Joint Arthroplasty/Replacement

can be in the knee, hip, or shoulder. Part of the joint is removed and replaced with a metal device for post care: prevention of dislocation, infection, and thromboembolism. Can use abductor pillow and turning. Assess for bleeding Manage anemia Early mobility is important with PT/OT For hip replacement, you never want to be sitting at more than a 90 degree angle

Graft or wound infections

can be life threatening. Use sterile technique when providing incisional care and observe for symptoms of infection. Assess the area for induration, erythema, tenderness, warmth, edema, or drainage. Also monitor for fever and leukocytosis (increased serum white blood cell count). Notify the surgeon promptly if any of these symptoms occur. Patients having conventional open bypass procedures are usually hospitalized for 5 to 7 days. Those having MIS procedures usually have shorter stays of 2 or 3 days.

sensible fluid loss

can be measured (includes fluid lost from defecation, urination, and wounds)

primary osteoarthritis

caused by aging and genetics

secondary osteoarthritis

caused by joint injury/excessive use and obesity

Surfactant

chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing

Fibromyalgia

chronic condition with widespread aching and pain in the muscles and fibrous soft tissue nerve pain NOT inflammatory

Systemic Sclerosis (Scleroderma)

chronic inflammatory autoimmune connective tissue disease. etiology unknown no cure hardening of skin and/or body systems can cause major organ damage affects more women than men focus is easing the symptoms by using high dose steroids and immunosuppresants can cause SOB and diarrhea diagnosed using labs similar to SLE

Opioid addiction

chronic neurologic and biologic disease. The development and characteristics of addiction are influenced by genetic, psychosocial, and environmental factors. No single cause of addiction such as taking an opioid for pain relief has been found. It is characterized by one or more of these behaviors: impaired control over drug use, compulsive use, continued use despite harm, and craving. The disease of addiction is a treatable disease; as for any other suspected disease, refer the patient to an expert for diagnosis and treatment.

agglutination

clumping of red blood cells; will result if blood types with different antigens are mixed; keeps out debris

Fully compensated

compensatory mechanism completely effective pH returns to normal

Buffers

constant, immediate act as sponges if acidic it soaks up hydrogen if alkaline it released hydrogen works in seconds

Drugs and Medications that cause hypertension

corticosteroids estrogen sympathomimetics cyclosporine erythropoietin meth and cocaine

Acute Respiratory Failure

cute respiratory failure (ARF) can be ventilatory failure, oxygenation (GAS EXCHANGE) failure, or a combination of both ventilatory and oxygenation failure and is classified by abnormal blood gas values. The critical values are: • Partial pressure of arterial oxygen (PaO2) less than 60 mm Hg (hypoxemic/oxygenation failure) • or Partial pressure of arterial carbon dioxide (PaCO2) more than 45 mm Hg occurring with acidemia (pH <7.35) (hypercapnic/ventilatory failure) • and Arterial oxygen saturation (SaO2) less than 90% in both cases Whatever the underlying problem, the patient in acute respiratory failure is always hypoxemic (has low arterial blood oxygen levels).

Cryptococcus neoformans

debilitating meningitis leading to systemic illness

Venous Insufficiency Interventions

decrease edema and promote venous return from the affected leg. The desired outcomes of managing venous stasis ulcers are to heal the ulcer, prevent infection, and prevent stasis with recurrence of ulcer formation. Interprofessional collaboration with the wound care nurse or wound, ostomy, and continence nurse (WOCN) is essential in providing ulcer care. A dietitian can suggest dietary supplements such as zinc and vitamins A and C, as well as high-protein foods, to promote wound healing. Patients with chronic venous insufficiency wear graduated compression stockings. Teach the patient to elevate his or her legs for at least 20 minutes four or five times per day. When the patient is in bed, remind him or her to elevate the legs above the level of the heart

Hypovolemia

decreased blood volume increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity >1.030

Hyponatremia Assessment

decreased cell excitability confusion, lethargy, weakness, sluggish, decreased DTR, dysrhythmias, seizures, SOB, shallow RR

lymphocytopneia

decreased number of lymphocytes opportunistic infection

Respiratory Alkalosis Causes

deficient CO2. excessive loss from hyperventilation due to anxiety, fear, improper ventilation, CNS impairment

IgD

function not fully understood

Fentanyl

differs from morphine significantly in characteristics. It is a lipophilic (readily absorbed in fatty tissue) opioid and, as such, has a fast onset and short duration of action. These characteristics make it the most commonly used IV opioid when rapid analgesia is desired such as for the treatment of severe, escalating acute pain and for procedural pain when a short duration of action is desirable. Fentanyl is the recommended opioid for patients with end-organ failure because it has no clinically relevant metabolites. It also produces fewer hemodynamic adverse effects than other opioids; therefore it is often preferred in patients who are hemodynamically unstable such as the critically ill.

Varicose Veins

distended, protruding veins that appear darkened and tortuous. They can occur in anyone, but they are common in adults older than 30 years whose occupations require prolonged standing or heavy physical activity. Varicose veins are also frequently seen in patients with systemic problems (e.g., heart disease), obesity, high estrogen states, and a family history of varicose veins. As the vein wall weakens and dilates, venous pressure increases, and the valves become incompetent (defective), causing venous reflux. The incompetent valves enhance the vessel dilation, and the veins become tortuous and distended.

Hyperkalemia Interventions

diuretic, stop supplement, dialysis, sodium polystyrene, insulin, sodium bicarb, watch glucose levels closely, telemetry, education

Gram Stain

does not determine the type of microbe; can not be used on a virus. determines whether the bacterial or fungal cell wall is gram positive or gram negative test usually takes about 10 min

Hypoventilation Causes

drug overdose pulmonary edema airway obstruction mechanical ventilation neuromuscular disease

Hypomagnesemia Assessment

dysrhythmias, torsads, SOB, dyspnea, confusion, irritable, seizures, increased DTR, twitching, slow GI motility

Hypokalemia Interventions

education, supplement, increase intake, stop vomiting or diarrhea, different diuretic, watch lab values, and signs and symptoms

pH affects

enzyme reactions cell and organ function drug metabolism tissue function

PAD Interventions

exercise/positioning do not cross legs no restrictive clothing inspect feet daily for color/ulcers limit cold exposure (promote vasodilation by keeping legs warm) *Caution the patient to avoid the application of direct heat to the limb with heating pads or extremely hot water. Sensitivity is decreased in the affected limb. Burns may result. smoking/tobacco cessation Drug Therapy: anti platelet agents, Treat HTN and high cholesterol. Invasive Nonsurgical Procedures: PVI, Atherectomy

HTN Interventions

fasting lipid profile sleep study accurate BP reading weight loss moderate alcohol, caffeine, and sodium intake smoking cessation stress reduction regular exercise relax biofeedback educate

Potassium Source

food must replace potassium every day Regulatory mechanism is the kidneys renal failure leads to high potassium- get to dialysis

Calcium source

food and supplements Required Vitamin D for activation Absorbed in GI tract Excreted through kidneys and stool

Liposomal bupivacaine (Exparel)

for postoperative wound infiltration is a sustained-release formulation injected as a single dose into the surgical site by the surgeon. The sustained-release formulation has been shown to produce prolonged analgesia, which decreases the need for potent opioids. For many years regional anesthesia has been administered by single-injection peripheral nerve blocks using a long-acting local anesthetic such as bupivacaine or ropivacaine to target a specific nerve or nerve plexus. This technique is highly effective in producing pain relief, but the effect is temporary (4-12 hours)

Topical local anesthetic creams

for superficial procedures such as IV insertion include EMLA (eutectic mixture of local anesthetics) and LMX-4- EMLA contains a combination of lidocaine 2.5% and prilocaine 2.5% and is applied to intact skin for 60 to 120 minutes before the procedure. LMX-4 contains 4% lidocaine and is applied 30 minutes before the procedure. EMLA has a longer duration of action (2 hours) than LMX-4 (30 minutes) after cream removal. Topical local anesthetic side effects are rare and usually transient, with local skin reactions being the most common.

Types of Anesthesia

general, regional, local

myeloid progenitor

give rise to erythrocytes and act quickly to kill an antigen

Fungi

group of organisms that include yeasts, molds, and mushrooms and can produce highly resistant spores

Methadone (Dolophine)

has the potential to produce analgesic effects as a second- or third-line option for some neuropathic pain states. Although it has no active metabolites, methadone has a very long and highly variable half-life (5 to 100+ hours; average is 20 hours). Patients must be watched closely for excessive sedation—a sign of drug accumulation during the titration period.

immunocompromised

having an impaired immune system

What two organs rely heavily on normal electrolyte balance

heart and brain

Hyperventilation Causes

high altitude. mechanical ventilation, acute pulmonary problems

Secondary Hypertension

high blood pressure caused by the effects of another disease (renal, endocrine) or certain drugs and medications.

nosocomial infection

hospital acquired infection: UTI, SSI, LRI, BSI Evaluate the need every 24 hours

Alkalosis Assessment

hyper excitable, seizures, hyper reflexes, cramping, tachycardia, dysrhythmia, increased RR and depth

do not administer a vaccine to any ____________________ patient

immunicompromised

Varicose Veins Treatment

improve and maintain optimal venous return to the heart and prevent disease progression. Conservative measures are the treatment of choice, including the three Es: elastic compression hose, exercise, and elevation. Graduated compression stockings (GCSs). Exercise increases venous return by helping the muscles pump blood back to the heart. Teach patients to avoid high-impact exercises such as horseback riding and running. Daily walks and ankle flexion exercises while sitting are common exercises that are helpful in promoting circulation. Elevating the extremities as much as possible allows gravity to work with the valves in promoting venous return and prevent reflux. Patients who continue to have pain or unsightly veins despite using the three Es may opt for more invasive approaches. Surgical ligation and/or removal of veins ("stripping") were the procedures of choice for many years. Sclerotherapy to occlude the affected vessel is also an option. endovenous ablation, which occludes the varicose vein, most commonly the saphenous vein. Using ultrasound guidance, the clinician advances a catheter into the vein and injects an anesthetic agent. Then the vessel is ablated (occluded) while the catheter is slowly removed.

Stages of Infection

incubation, prodromal, illness, decline, convalescence

Chain of Infection

infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host

Airborne precautions

infectious microbes suspended in air ex: measles, tuberculosis, varicella negative pressure room, anti-room for PPE, N-95

Rhinoplasty

is a surgical reconstruction of the nose. It can be performed to repair a fractured nose and also to change the shape of the nose. The patient returns from surgery with packing in both nostrils, which prevents bleeding and provides support for the reconstructed nose. As long as the packing is in place, the patient cannot breathe through the nose. A "moustache" dressing (or drip pad), often a folded 2 × 2 gauze pad, is usually placed under the nose (Fig. 29-2). A splint or cast may cover the nose for better alignment and protection. Change or teach the patient to change the drip pad as necessary. After surgery observe for edema and bleeding. Check vital signs every 4 hours until the patient is discharged. Assessing how often the patient swallows after nasal surgery is a priority because repeated swallowing may indicate posterior nasal bleeding. Use a penlight to examine the throat for bleeding and notify the surgeon if bleeding is present. Instruct the patient to stay in a semi-Fowler's position and to move slowly. Suggest that he or she rests and uses cool compresses on the nose, eyes, and face to help reduce swelling and bruising. If a general anesthetic was used, soft foods can be eaten once the patient is alert and the gag reflex has returned. Urge the patient to drink at least 2500 mL/day. To prevent bleeding, teach the patient to limit Valsalva maneuvers (e.g., forceful coughing or straining during a bowel movement), not to sniff upward or blow the nose, and not to sneeze with the mouth closed for the first few days after the packing is removed. Instruct the patient to avoid aspirin and other NSAIDs to prevent bleeding. Antibiotics may be prescribed to prevent infection. Recommend the use of a humidifier to prevent mucosal drying. Explain that edema lasts for weeks and that the final surgical result will be evident in 6 to 12 months.

Versed (midazolam)

pre-surgical sedation

Management of Transplant Rejection

lifeline medications- one time same time daily corticosteroids calcineurin inhibitors and anti-proliferative agents are selective and target depends on organ and patient increased risk for infection

Hypermagnesemia Interventions

limit intake, increase phosphorous, decrease calcium, stop supplements and antacids, diuretic, dialysis, calcium gluconate

Hypertension and RAS

limit sodium intake -> avoid water retention -> avoid increased blood volume -> regulate BP Drug therapy for BP: -diuretics -ACE inhibitors -ARBs

E. Coli

lives in digestive tract and keeps it healthy. found in gut of animals transmitted by contact or ingestion. Transmitted by poor hand hygiene, foods and cross contamination, raw unpasteurized milk, water in lakes/ponds/streams Symptoms: Diarrhea, cramping, fever, chills, body aches Can cause GI Infections, UTI, pneumonia Need a clean catch culture and C&S Report Gram negative bacteria Carbapenem Resistant

Scleroderma Nursing Care

local skin protectant mild soaps and lotions skin ulcer treatment modify room temperature speech language and pathology small frequent meals elevate HOB 3-4 hrs after eating antacids pain control education

Gout Interventions

low purine diet avoid organ meats, shellfish and oily fish, alcohol drink plenty of fluids Colchicine and NSAIDS for acute allopurinol for chronic goal is to manage attacks and inflammation

Hypernatremia Interventions

low to no sodium intake, limit water, isotonic fluid or hypotonic fluid, diuretics, intake and output, look for increased output, reassess for overcorrection

Laboratory Assessment w/ HIV

lymphocyte counts to determine if WBC is below 3500 (leukopenia) CD4 T cell and CD8 T cell count to establish the client's baseline. Drawn every 3-6 months Viral load testing in 4 month intervals; measures the RNA. Vital in order to measure progression of the disease and the effectiveness of treatment Blood chemistries, CBC, stool testing, biopsies

Acetaminophen and NSAIDs

make up the nonopioid analgesic group. Acetaminophen is thought to relieve pain by underlying mechanisms in the CNS. It has analgesic and antipyretic properties but is not effective for treating inflammation. In contrast, NSAIDs have analgesic, antipyretic, and anti-inflammatory properties.

ezetimibe

may be used in place of or in combination with statin-type drugs. This drug inhibits the absorption of cholesterol through the small intestine. Vytorin is a combination drug containing ezetimibe and simvastatin. This drug works two ways—by reducing the absorption of cholesterol and by decreasing the amount of cholesterol synthesis in the liver. Other statin combinations have been developed to improve lipid levels, such as Advicor—a combination of niacin and lovastatin. Aspirin and pravastatin are combined as Pravigard. Amlodipine (Norvasc) and atorvastatin are combined as Caduet to decrease blood pressure while decreasing triglycerides (TGs), increasing HDL, and lowering LDL. Combining drugs may improve adherence for the patient who is often taking multiple drugs.

Fluid Volume Defecit

measure all fluids that enter and leave check lytes, CBC, and urine gravity Assess for hypotension and weak pulse Assess resp. system and tissue perfusion check orientation, vision, hearing, reflexes, and muscle strength check for weight changes check for skin breakdown and mucous membranes

Multidrug-resistant organisms

microbes that can resist the effects of antibiotics caused by taking antibiotics when not needed or not taking antibiotics for full length of time, biofilm patient at high risk for morbidity and mortality with limited antibiotics MRSA and VRE

Nonsurgical Management of Aneurysms

monitor the growth of the aneurysm and maintain the blood pressure at a normal level to decrease the risk for rupture. Patients with hypertension are treated with antihypertensive drugs to decrease the rate of enlargement and the risk for early rupture. For those with small or asymptomatic aneurysms, frequent ultrasound or CT scans are necessary to monitor the growth of the aneurysm. Emphasize the importance of following through with scheduled tests to monitor the growth. Also explain the signs and symptoms of aneurysms that need to be promptly reported.

rheumatiod arthritis (RA)

most destructive chronic, progressive, systemic inflammatory Autoantibodies attack: joints, especially synovial joints, cartilage, joint capsule, and surrounding ligaments thickens the synovium and forms a pannus which erodes the cartilage and the bone autoimmune can develop scar tissue, bony ankyloses, calcifications

HTN Assessment

mostly asymptomatic. headache, dizziness; facial flushing, nose bleeds, stress anginal pain intermittent claudication- decreased adequacy of blood supply to the legs during periods of activity retinal hemorrhages and exudates severe occipital headaches associated with nausea, vomiting, drowsiness, giddiness, anxiety, mental impairment due to vessel damage within the brain dyspnea upon exertion- left-sided heart failure edema of the extremities- right-sided heart failure Review history and risk factors such as renal disease, endocrine disease, and medications.

SLE symptoms

mouth and nose ulcers butterfly rash and red patches lung inflammation and hemorrhage blood in urine hair loss fever -> exacerbation headache FATIGUE heart inflammation severe abdominal pain anemia high blood pressure muscle joint pain and swelling

3. Is the HCO3 normal?

normal range is 22-26 acidosis is less than 22 alkalosis is greater than 26

Physical dependence

normal response that occurs with repeated administration of an opioid for several days. It is manifested by the occurrence of withdrawal symptoms when the opioid is stopped suddenly or rapidly reduced or an antagonist such as naloxone is given. Withdrawal symptoms may be suppressed by the natural, gradual reduction of the opioid as pain decreases or by gradual, systematic reduction, referred to as tapering. Physical dependence is not the same as addictive disease.

PACU nurse

nurses anticipate, prevent, and manage complications after surgery. The PACU, usually a large and open room that provides direct observation of all patients and easy access to supplies and emergency equipment, is usually located close to the surgical suite for ease of access and patient transfer. The patient area may be divided into individual cubicles, and privacy is managed using ceiling mounted curtains or floor screens that are fully closed during bedside procedures. Each cubicle has equipment to monitor and care for the patient such as oxygen, suction equipment, cardiac monitors, pulse oximetry, airway equipment, and emergency drugs. The PACU nurse is skilled in the care of patients with multiple medical and surgical problems immediately after a surgical procedure. This area requires in-depth knowledge of anatomy and physiology, anesthetic agents, pharmacology, pain management, airway management, surgical procedures, and advanced cardiac life support (ACLS). The PACU nurse is skilled in assessment and can make knowledgeable, critical decisions if emergencies or complications occur. The patient is monitored continuously, and the anesthesia provider and surgeon are consulted as needed.

Venous insufficiency

occurs as a result of prolonged venous hypertension that stretches the veins and damages the valves. Valvular damage can lead to a backup of blood and further venous hypertension, resulting in edema and decreased tissue perfusion. With time, this stasis (stoppage) results in venous stasis ulcers, swelling, and cellulitis. The veins cannot function properly when thrombosis occurs or when valves are not working correctly. Venous hypertension can occur in people who stand or sit in one position for long periods (e.g., teachers, office personnel). Obesity can also cause chronically distended veins, which lead to damaged valves. Thrombus formation can contribute to valve destruction. Chronic venous insufficiency also often occurs in patients who have had thrombophlebitis. In severe cases, venous ulcers develop.

Body's Primary regulators of fluid balance

oral intake 2-3L per day urine output of 400-600mL per day about 30mL per hour

dehydration Interventions

oral intake: water or sports drink IV fluids anti diarrheal antiemetics may need oxygen maintain fluid elimination if NPO

autologous

originating within an individual

ABG Values

pH: 7.35-7.45 PaO2: 80-100% >60 for COPD pt PaCO2: 35-45 (acidic= 45, alkalotic= 35) HCO3: 22-26

Pain

pain is whatever the experiencing person says it is and exists whenever he or she says it exists. This has become the clinical definition of pain worldwide and reflects an understanding that the patient is the authority and the only one who can describe the pain experience. In other words, self-report is always the most reliable indication of pain. Nurses who approach pain from this perspective can help the patient achieve effective management by advocating for proper control. If the patient cannot provide self-report, a variety of other methods such as observation of behavioral indicators are used for pain assessment

Pre Op Drugs

pg. 247

pneumocystis pneumonia

pneumonia caused by a yeast like fungus organism, a common opportunistic infection in those who are positive for the human immunodeficiency virus (HIV) takes several weeks to develop and only a mild fever

Priority patient problems with HIV

potential for infection inadequate oxygenation pain inadequate nutrition diarrhea reduced skin integrity confusion reduced self esteem potential loss of social contact

Prevention of Complications Related to Intraoperative Positioning

prevention of Brachial Plexus Complications (Paralysis, Loss of Sensation in Arm and Shoulder) • Pad the elbow if tucked at the side. • Avoid excessive abduction (less than 90 degrees). • 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 (do not overtighten). • Place the arm of supine patient with palm up. 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.

epiglottis function

prevents food from going into the trachea and instead directs it to the esophagus PREVENTS ASPIRATION

cytokines

produced by WBC and T cells messengers- tell other cells how and when to respond

Osteoarthritis

progressive deterioration, loss of cartilage and bone in one or more joints cartilage and fluids decline osteophytes (bone spurs) are calcium deposits; secondary joint inflammation crepitus is where the cartilage disintegrates causing floating pieces of bone no cure can lead to muscle atrophy the inflammation is caused by the PROCESS not the disease

Helper T cells

recognize self vs non self, enhance activity of other WBC

Oral acetaminophen (Tylenol, Abenol)

recommended as first line for musculoskeletal pain (e.g., osteoarthritis) in older adults but has no inflammatory properties. Therefore acetaminophen is less effective than NSAIDs for chronic inflammatory pain (e.g., rheumatoid arthritis). IV acetaminophen (Ofirmev) is approved for treatment of pain and fever in adults and is given by a 15-minute infusion in single or repeated doses. It can be given alone for mild-to-moderate pain or in combination with opioid analgesics for more severe pain. The most serious complication of acetaminophen is hepatotoxicity (liver damage) as a result of overdose. Patient's hepatic risk factors must always be considered before administration of acetaminophen.

Aneurysms of the Peripheral Arteries TREATMENT

recommended treatment for either type of aneurysm, regardless of size, is surgery because of the risk for thromboembolic complications. To treat a femoral aneurysm, the surgeon removes the aneurysm and restores circulation using a synthetic or an autogenous saphenous vein graft-stent repair. Most surgeons prefer to bypass rather than resect a popliteal aneurysm. After surgery, monitor for lower-limb ischemia. Palpate pulses below the graft to assess graft patency. Often Doppler ultrasonography is necessary to assess blood flow when pulses are not palpable. Report sudden development of pain or discoloration of the extremity immediately to the surgeon because it may indicate graft occlusion.

Discoid Lupus

red to pink papules and plaques of face, scalp, ear canal, follicular plugging, eventual atrophic scarring can be induced by medications such as procainamide or hydralazine diagnosed by a skin biopsy

Local anesthetics

relieve pain by blocking the generation and conduction of the nerve impulses necessary to transmit pain. The local anesthetic effect is dose related. A high enough dose of local anesthetic can produce complete anesthesia, and a low enough dose (subanesthetic) can produce analgesia. Local anesthetics have a long history of safe and effective use for the treatment of all types of pain. Allergy to local anesthetics is rare, and side effects are dose-related. CNS signs of systemic toxicity include ringing in the ears, metallic taste, irritability, and seizures. Signs of cardiotoxicity include tingling and numbness, bradycardia, cardiac dysrhythmias, and cardiovascular collapse

Antidepressants

relieve pain on the descending modulatory pathway by blocking the body's reuptake of the inhibitory neurochemicals norepinephrine and serotonin. Antidepressant adjuvant analgesics are divided into two major groups: the tricyclic antidepressants (TCAs) and the newer serotonin and norepinephrine reuptake inhibitors (SNRIs). Evidence-based guidelines recommend the TCAs desipramine (Norpramin) and nortriptyline (Aventyl, Pamelor) and the SNRIs duloxetine (Cymbalta) and venlafaxine (Effexor) as first-line options for neuropathic pain treatment (D'Arcy, 2014). The most common side effects of the TCAs are dry mouth, sedation, dizziness, mental clouding, weight gain, and constipation. Orthostatic hypotension is a potentially serious TCA side effect, making TCAs a poor choice for older adults. The most serious adverse effect is cardiotoxicity, especially for patients with existing significant heart disease. The SNRIs have a more favorable side effect profile and are better tolerated than the TCAs. The most common SNRI side effects are nausea, headache, sedation, insomnia, weight gain, impaired memory, sweating, and tremors.

Transplant surgery

replaces a malfunctioning body part, tissue, or organ

partially compensated

respiratory problem too severe and renal compensatory mechanism cannot overcome imbalance pH does not return to normal

Fishbone

salty buns bananas with coffee, cream, and sugar

respiratory compensation

sensitive to pH changes acts quickly seconds to minutes Limited, easily overwhelmed The lungs can compensate for imbalances that are metabolic in origin--- changes in respiratory pattern

Field Blocks

series of injections around operative area

malignant hypertension

severe and rapid high blood pressure that can damage internal organs

HIV Transmission

sexual contact, sharing needles, needle stick, mother to baby blood, semen, pre-seminal fluid, vaginal fluid, rectal fluid, breast milk

Hypomagnesemia Interventions

supplment, vitamin D, increased Calcium and Decrease Phosphorus, change intake of diuretic if needed, monitor cardiac, respiratory, watch lab trands

protozoa

single celled parasitic organisms with flexible membranes that live in the soil and obtain nutrients from dead or decaying organic material such as raw meat; infect humans through fecal-oral contamination

Hypermagnesemia Assessment

telemetry, low BP, low HR, cardiac arrest and no movement is possible, slow and shallow RR, depressed, altered LOC, lethargic, coma is possible, decreased DTR, weakness everything slows down because there is no membrane exchange

Hypercalcemia Interventions

stop supplement, change diuretic if needed limit magnesium, increase phosphorous, calcitonin, prevent injury and increased risk for blood clots

Things that can affect immunity

stress, poor sleep, mental illness, poor nutrition, drugs, environment, poverty

Uncontrolled hypertension can lead to

stroke vision loss HF, MI Kidney disease Sexual dysfunction to be continued..

Electrolytes

substances dissolved in body fluid and carry an electrical charge cations are positive anions are negative

Suppressor T cells

suppress most cells of the immune system and prevent hypersensitivity

-ostomy

surgery of the bowel

Urgent Surgery

surgery that is not an emergency, but must be done within a reasonably short time frame (24-48hrs) to preserve health Intestinal obstruction Bladder obstruction Kidney or ureteral stones Bone fracture Eye injury Acute cholecystitis

-plasty

surgical correction or repair

-automy

surgical incision

minimally invasive surgery

surgical procedures that use specialized instruments inserted into the body either through natural orifices or through small incisions. Arthroscopy Tubal ligation Hysterectomy Lung lobectomy Coronary artery bypass Cholecystectomy

Atherectomy

surgical removal of plaque buildup from the interior of an artery

Bouchard's nodes

swelling at the proximal interphalangeal joints in osteoarthritis involving the hands

Nociceptive Pain

term that is used to describe how pain becomes a conscious experience. It involves the normal functioning of physiologic systems that process noxious stimuli, with the ultimate result being that the stimuli are perceived to be painful. In short, nociception means "normal" pain transmission and is generally discussed in terms of four processes: transduction, transmission, perception, and modulation

Preemptive analgesia

the administration of local anesthetics, opioids, and other drugs (multimodal analgesia) in anticipation of pain along the continuum of care during the preoperative, intraoperative, and postoperative periods. This continuous approach is designed to decrease pain severity in the postoperative period, reduce analgesic dose requirements, prevent morbidity, shorten hospital stay, and avoid complications after discharge.

After an arterial thrombectomy, observe...

the affected extremity for improvement in color, temperature, and pulse every hour for the first 24 hours or according to the postoperative surgical protocol. Monitor patients for manifestations of new thrombi or emboli, especially pulmonary emboli (PE). Chest pain, dyspnea, and acute confusion (older adults) typically occur in patients with PE. Notify the health care provider or Rapid Response Team immediately if these symptoms occur.

Immunity Process

the immune system fights invading organisms by recognizing self vs. non self

Bronchoscopy

the insertion of a tube in the airways as far as the secondary bronchi to view airway structures and obtain tissue samples. 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 ICU or a special endoscopy suite with low-dose sedation. It is used to evaluate the airway and to help 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. Stents can be placed during bronchoscopy to open up strictures in the trachea and bronchus

Morphine

the most widely used opioid throughout the world, particularly for cancer pain, and its use is established by extensive research and clinical experience. Morphine is a hydrophilic drug (readily absorbed in aqueous solution), which accounts for its slow onset and long duration of action when compared with other opioid analgesics. It is available in a wide variety of short-acting and modified-release oral formulations and is given by multiple other routes of administration, including rectal, subcutaneous, and IV.

Thoracentesis

the needle aspiration of pleural fluid or air from the pleural space for diagnostic or management purposes. Microscopic examination of the pleural fluid helps in making a diagnosis. Pleural fluid may be drained to relieve blood vessel or lung compression and the respiratory distress caused by cancer, empyema, pleurisy, or tuberculosis. Drugs can also be instilled into the pleural space during thoracentesis.

Idiopathic Pulmonary Fibrosis: Assessment

the onset is slow, with early symptoms of mild dyspnea on exertion. Pulmonary function tests show decreased forced vital capacity (FVC). High-resolution computed tomography (HRCT) shows a "honeycomb" pattern in affected lung tissue. As the fibrosis progresses, the patient becomes more dyspneic, and hypoxemia becomes severe. Eventually he or she needs high levels of oxygen and often is still hypoxemic. Respirations are rapid and shallow.

Acute Peripheral Arterial Occlusion

the onset of acute arterial occlusions is sudden and dramatic. An embolus (piece of a clot that travels and lodges in a new area) is the most common cause of peripheral occlusions, although a local thrombus may be the cause. Occlusion may affect the upper extremities, but it is more common in the lower extremities. Emboli originating from the heart are the most common cause of acute arterial occlusions. Most patients with an embolic occlusion have had an acute myocardial infarction (MI) and/or atrial fibrillation within the previous weeks.

Nociceptive pain

the result of actual or potential tissue damage or inflammation and is often categorized as being somatic or visceral. Somatic pain arises from the skin and musculoskeletal structures, and visceral pain arises from organs. Examples include pain-associated trauma, surgery, burns, and tumor growth.

Risk Factors of electrolyte imbalance

the very young and very old renal system disorders endocrine disorders chronic illnesses medications

Hypocalcemia Assessment

thyroid history increased risk for bleeding telemetry Respiratory spasms, SOB, dyspnea, irritated, restlessness, seizures, weak bones., positive Chvostek and positive Palmar flexion Trousseaus

Tramadol

used for both acute and chronic pain and is available in oral short-acting (Ultram) and modified-release (Ultram ER) formulations, including a short-acting tablet in combination with acetaminophen (Ultracet). It is appropriate for acute pain and has been designated as a second-line analgesic for the treatment of neuropathic pain. Side effects are similar to those of opioids. The drug can lower seizure threshold and interact with other drugs that block the reuptake of serotonin such as the selective serotonin reuptake inhibitor (SSRI) antidepressants. Although rare, this combination can have an additive effect and result in serotonin syndrome, characterized by agitation, diarrhea, heart and blood pressure changes, and loss of coordination.

Intrathecal (spinal) analgesia

usually delivered via single bolus technique for patients with acute pain (e.g., hysterectomy) or continuous infusion via an implanted device (pump) for the treatment of chronic pain. Because the drug is delivered directly into the aqueous cerebrospinal fluid (CSF), morphine with its hydrophilic nature is used most often for intrathecal analgesia. Extremely small amounts of drug are administered by the intrathecal route (about 10 times less than by the epidural route) because the drug is so close to the spinal action site.

VRE

vancomycin resistant enterococcus an infection resistant to Vancomycin bacteria that lives in the intestine without disease transferred by contact same symptoms as MRSA Risks: long term Vanc or antibiotic use, decreased immune system, abdominal or chest surgery, medical devices, kidney disease, blood disorder diagnosed with a culture

-scopy

visual examination

endoscopy

visual examination within a hollow organ

Compensation

word we use to describe the body attempt to adapt in response to changes in the blood pH and maintain acid base balance Below 6.9 or above 7.8 is usually fatal Two means: respiratory and metabolic (renal)

Helmiths

wormlike parasitic animals; roundworms, flatworms, tapeworms, pinworms, and flukes

Teach patients receiving treatment for hypertension about the importance of continuing to take prescribed drugs. Instruct them about the signs and symptoms that must be reported promptly to the primary health care provider, which include:

• Abdominal fullness or pain or back pain • Chest or back pain • Shortness of breath • Difficulty swallowing or hoarseness

The patient is expected to be free of injury as indicated by:

• Adequate capillary refill and peripheral pulses in all extremities • Sensory perception and motor function after surgery at the same level as before surgery • Absence of injury to the skin (redness, open skin areas, bruising, burns) • Absence of retained surgical items

Intraoperative Nursing Interventions: Older Adult

• Allow patients to retain eyeglasses, dentures, and hearing aids until anesthesia has begun. • Use a small pillow under the patient's head if his or her head and neck are normally bent slightly forward. • Lift patients into position to prevent shearing forces on fragile skin. • Position arthritic and artificial joints carefully to prevent postoperative pain and discomfort from strain on those joints. • Pad bony prominences to prevent pressure sores. • Provide extra padding for patients with decreased peripheral circulation. • Use warming devices to prevent hypothermia. • Cover the patient's head and feet. • Warm IV and irrigation fluids as indicated by agency policy and manufacturer recommendations. • Follow strict aseptic technique. • Carefully monitor intake and output, including blood loss.

Care of the Patient With a Pulmonary Embolism

• Apply oxygen by nasal cannula or mask. • Reassure patient that the correct measures are being taken. • Place patient in high-Fowler's position. • Apply telemetry monitoring equipment. • Obtain an adequate venous access. • Assess oxygenation continuously with pulse oximetry. • Assess respiratory status at least every 30 minutes by: • Listening to lung sounds. • Measuring the rate, rhythm, and ease of respirations. • Checking skin color and capillary refill. • Checking position of trachea. • Assess cardiac status by: • Comparing blood pressures in right and left arms. • Checking pulse for quality. • Checking cardiac monitor for dysrhythmias. • Checking for distention of neck veins. • Ensure that prescribed chest imaging and laboratory tests are obtained immediately (may include complete blood count with differential, platelet count, prothrombin time, partial thromboplastin time, D-dimer level, arterial blood gases). • Examine the thorax for presence of petechiae. • Administer prescribed anticoagulants. • Assess for bleeding. • Handle patient gently. • Institute Bleeding Precautions.

The patient with head and neck cancer is expected to attain and maintain adequate GAS EXCHANGE and tissue oxygenation. Indicators include:

• Arterial blood gas values within the normal range • Rate and depth of respiration within the normal range • Pulse oximetry within the normal range

The patient is expected to have an uninfected surgical wound or wounds. Indicators include:

• Aseptic technique is maintained throughout the surgical procedure. • 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.

Nursing Focus on the Older Adult Assessment of Pain

• Ask the patient to provide his or her own report of pain; even mild to some moderate cognitively impaired older adults are able to provide self-report if nurses and caregivers take the time to obtain it. • Offer various self-report pain tools. • Always show tools in hard copy with large lettering, adequate space between lines, nonglossy paper, and color for increased visualization. • Be sure that the patient is wearing glasses and hearing aids if needed and available. • Provide adequate lighting and privacy to avoid distracting background noise. • Repeat questions more than once and allow adequate time for response. • Use verbal descriptions such as "ache," "sore," and "hurt" if the patient seems to have difficulty relating to the word "pain." • Ask about present pain only. • If the patient is able to use a self-report tool, use the same tool and reteach the tool each time pain is assessed.

Tracheostomy Care

• Assemble the necessary equipment. • Wash hands. Maintain Standard Precautions. • Suction the tracheostomy tube if necessary. • Remove old dressings and excess secretions. • Set up a sterile field. • Remove and clean the inner cannula. Use half-strength hydrogen peroxide to clean the cannula and sterile saline to rinse it. If the inner cannula is disposable, remove the cannula and replace it with a new one. • Clean the stoma site and then the tracheostomy plate with half-strength hydrogen peroxide followed by sterile saline. Ensure that none of the solutions enters the tracheostomy. • Change tracheostomy ties if they are soiled. Secure new ties in place before removing soiled ones to prevent accidental decannulation. If a knot is needed, tie a square knot that is visible on the side of the neck. Only one finger should be able to be placed between the tie tape and the neck. • Wash hands. • Document the type and amount of secretions and the general condition of the stoma and surrounding skin tissue integrity. Document the patient's response to the procedure and any teaching or learning that occurred. Prevent decannulation during tracheostomy care by keeping the old ties or holder on the tube while applying new ties or holder or by keeping a hand on the tube until it is securely stable. (This is best performed with the assistance of a coworker.)

Nursing Interventions to Prevent and Treat Selected Opioid Side Effects: Constipation

• Assess previous bowel habits. • Keep a record of bowel movements. • Remind patients that tolerance to this side effect does not develop, so a preventive approach must be used; administer a stool softener plus mild stimulant laxative for duration of opioid therapy; do not give bulk laxatives because these can result in obstruction in some patients. • Provide privacy, encourage adequate fluids and activity, and give foods high in roughage. • If ineffective, try suppository or Fleet's enema. • For long-term opioid-induced constipation (OIC) in patients with chronic pain, drug therapy may be used (e.g., lubiprostone [Amitiza], methylnaltrexone [Relistor]).

Nursing Interventions to Prevent and Treat Selected Opioid Side Effects: Respiratory Depression

• Be aware that counting respiratory rate alone does not constitute a comprehensive respiratory assessment. Proper assessment of respiratory status includes observing the rise and fall of the patient's chest to determine depth and quality in addition to counting respiratory rate for 60 seconds. • Recognize that snoring is respiratory obstruction and an ominous sign (see text). • Remember that sedation precedes opioid-induced respiratory depression; identify patient and iatrogenic risk factors and monitor sedation level and respiratory status frequently during the first 24 hours of opioid therapy (see Sedation section). • Stop opioid administration immediately for clinically significant respiratory depression, stay with patient, continue attempts to arouse patient, support respirations, call for help (consider Rapid Response Team or Code Blue), and consider giving naloxone. • Reassure patients taking long-term opioid therapy that tolerance to this side effect develops with regular daily opioid doses.

Suctioning the Artificial Airway

• Assess the need for suctioning (routine unnecessary suctioning causes mucosal damage, bleeding, and bronchospasm). • Wash hands. Don protective eyewear. Maintain Standard Precautions. • Explain to the patient that sensations such as shortness of breath and coughing are to be expected but that any discomfort will be very brief. • Check the suction source. Occlude the suction source and adjust the pressure dial to between 80 and 120 mm Hg to prevent hypoxemia and trauma to the mucosa. • Set up a sterile field. • Preoxygenate the patient with 100% oxygen for 30 seconds to 3 minutes (at least three hyperinflations) to prevent hypoxemia. Keep hyperinflations synchronized with inhalation. • Quickly insert the suction catheter until resistance is met. Do not apply suction during insertion. • Withdraw the catheter 0.4 to 0.8 inch (1 to 2 cm) and begin to apply suction. Apply continuous suction and use a twirling motion of the catheter during withdrawal to avoid injury to TISSUE INTEGRITY. Never suction longer than 10 to 15 seconds. • Hyperoxygenate for 1 to 5 minutes or until the patient's baseline heart rate and oxygen saturation are within normal limits. • Repeat as needed for up to three total suction passes. • Suction mouth as needed and provide mouth care. • Remove gloves and wash hands. • Describe secretions and document patient's responses.

Communicating With a Patient Who Is Unable To Speak

• Assess the patient's reading skills and cognition. • Determine in what language (languages) the patient is most fluent. • Collaborate with a speech and language pathologist. • If the patient requires vision-enhancing or hearing-enhancing devices, be sure these are available and in use. • Provide the patient with a variety of techniques to practice before verbal skills are lost to determine with which one(s) the patient feels most comfortable. These may include: • Alphabet board • Picture board • Paper and pencil • Magic Slate • Hand signals/gestures • Computer with e-triloquist program • Programmable speech-generating devices (text-to-speech communication aid) • Reinforce to the patient the technique for esophageal speech presented by the speech and language pathologist and provide the time for practice. • Use a normal tone of voice to talk with the patient (unless hearing is a pre-existing problem, a change in the ability to speak does not interfere with the patient's ability to hear). • Ensure that the call-light board at the nurses' station indicates a nonspeaking patient. • Teach the patient to make noise to indicate that immediate attention is needed at the bedside when he or she signals by call light. Such noises can include tapping the side rail with a spoon, making clicking noises with the tongue, using a bell, or working a noisemaker. Be sure that whatever method is selected is listed on the call-light board. • When face-to-face with the patient: • Phrase questions in a "yes" or "no" format. • Watch the patient's face for indications of understanding or the lack of it. • Listen attentively to any sound the patient makes. • If writing is selected as the method to communicate, assess whether the patient is right handed or left handed and ensure appropriate writing materials are within reach. Use the other arm for IV placement. • Ensure that the preferred method of communication is documented in the patient record and is communicated to all care providers. • Encourage the family to work with the patient in the use of the selected method. • Provide praise and encouragement. • Do not avoid talking with the patient. • Allow the patient to set the pace for communication.

The nurse's role in providing regional anesthesia includes:

• Assisting the anesthesia provider • Positioning the patient comfortably and safely • Offering information and reassurance • Staying with the patient and providing emotional support • Observing for breaks in sterile technique • Recognizing and responding to signs and symptoms of possible reactions to the anesthetics

Evaluate the care of the patient with a tracheostomy based on the identified priority patient problems. The expected outcomes of care are that the patient should:

• Attain and maintain GAS EXCHANGE at a level within his or her chronic baseline values • Communicate effectively • Achieve and maintain a body weight within 10% of his or her ideal weight • Avoid serious respiratory infections • Maintain TISSUE INTEGRITY of the airway mucosa and skin surrounding the tracheostomy.

Patient and Family Education: Preparing for Self-Management Asthma Management

• Avoid potential environmental asthma triggers, such as smoke, fireplaces, dust, mold, and weather changes of warm to cold. • Avoid drugs that trigger your asthma (e.g., aspirin, NSAIDs, beta blockers). • Avoid food that has been prepared with monosodium glutamate (MSG) or metabisulfite. • If you have exercise-induced asthma, use your bronchodilator inhaler 30 minutes before exercise to prevent or reduce bronchospasm. • Be sure that you know the proper technique and correct sequence when you use metered dose inhalers. • Get adequate rest and sleep. • Reduce stress and anxiety; learn relaxation techniques; adopt coping mechanisms that have worked for you in the past. • Wash all bedding with hot water to destroy dust mites. • Monitor your peak expiratory flow rates with a flow meter at least twice daily. • Seek immediate emergency care if you experience any of these: • Gray or blue fingertips or lips • Difficulty breathing, walking, or talking • Retractions of the neck, chest, or ribs • Nasal flaring • Failure of drugs to control worsening symptoms • Peak expiratory rate flow (PERF) declining steadily after treatment, or a flow rate 50% below your usual flow rate

Preventing Aspiration During Swallowing (trach)

• Avoid serving meals when the patient is tired. • Provide smaller and more frequent meals. • Provide adequate time; do not "hurry" the patient. • Provide close supervision if the patient is self-feeding. • Keep emergency suctioning equipment close at hand and turned on. • Avoid water and other "thin" liquids. • Thicken all liquids, including water. • Avoid foods that generate thin liquids during the chewing process such as fruit. • Position the patient in the most upright position possible. • When possible, completely (or at least partially) deflate the tube cuff during meals. • Suction after initial cuff deflation to clear the airway and allow maximum comfort during the meal. • Feed each bite or encourage the patient to take each bite slowly. • Encourage the patient to "dry swallow" after each bite to clear residue from the throat. • Avoid consecutive swallows of liquids. • Provide controlled small volumes of liquids, using a spoon. • Encourage the patient to "tuck" his or her chin down and move the forehead forward while swallowing. • Allow the patient to indicate when he or she is ready for the next bite. • If the patient coughs, stop the feeding until he or she indicates that the airway has been cleared. • Continuously monitor tolerance to oral food intake by assessing respiratory rate, ease, pulse.

Home Laryngectomy Care

• Avoid swimming and use care when showering or shaving. • Lean slightly forward and cover the stoma when coughing or sneezing. • Wear a stoma guard or loose clothing to cover the stoma. • Clean the stoma with mild soap and water. Lubricate the stoma with a non-oil-based ointment as needed. • Increase humidity by using saline in the stoma as instructed, a bedside humidifier, pans of water, and houseplants. • Obtain and wear a MedicAlert bracelet and emergency care card for life-threatening situations.

Intraoperative Autologous Blood Salvage and Transfusion

• Be aware of the cell-processing method to be used. • Make sure that collection containers are labeled for the patient. • Assist with sterile setup as necessary. • Assist with processing and reinfusing procedures as needed. • Document the transfusion process. • Monitor the patient's vital signs during the transfusion procedure.

Pain Assessment in Advanced Dementia (PAINAD) scale has been tested in patients with severe dementia (Herr et al., 2011). The tool groups behavioral indicators into five categories for scoring using a graduated scale of 0 (least intense behaviors) to 2 (most intense behaviors) per category for a maximum behavioral score of 10:

• Breathing (independent of vocalization) • Negative vocalization • Facial expression • Body language • Consolability (ability to calm the patient) For patients who are mechanically ventilated or may not be able to use other tools for communication, try these interventions: • Establish a reliable yes-no signal (e.g., thumbs up or down, head nods, or eye blinks) to determine the presence of pain. • Use communication boards, alphabet boards, computer, or picture boards with word labels for patients with COGNITION problems. • Correctly interpret lip reading by maintaining eye contact, encouraging the patient to speak slowly, and using dentures if required.

Best Practice for Patient Safety & Quality Care The Patient Receiving Anticoagulant Therapy

• Carefully check the dosage of anticoagulant to be administered, even if the pharmacy prepared the drug. • Monitor the patient for signs and symptoms of bleeding, including hematuria, frank or occult blood in the stool, ecchymosis, petechiae, altered mental status (indicating possible cranial bleeding), or pain (especially abdominal pain, which could indicate abdominal bleeding). • Monitor vital signs frequently for decreased blood pressure and increased pulse (indicating possible internal bleeding). • Have antidotes available as needed (e.g., protamine sulfate for heparin; vitamin K for warfarin [Coumadin, Warfilone]). • Monitor activated partial thromboplastin time (aPTT) for patients receiving unfractionated heparin. Monitor prothrombin time (PT)/international normalized ratio (INR) for patients receiving warfarin or low-molecular-weight heparin (LMWH). • Apply prolonged pressure over venipuncture and injection sites. • When administering subcutaneous heparin, apply pressure over the site and do not massage. • Teach the patient going home while taking an anticoagulant to: • Use only an electric razor • Take precautions to avoid injury (e.g., do not use tools such as hammers or saws where accidents commonly occur) • Report signs and symptoms of bleeding, such as blood in the urine or stool, nosebleeds, ecchymosis, or altered mental status • Take the prescribed dosage of drug at the precise time that it was prescribed to be taken • Do not stop taking the drug abruptly; the health care provider usually tapers the anticoagulant gradually

Best Practice for Patient Safety & Quality Care Oxygen Therapy

• Check the health care provider's prescription with the type of delivery system and liter flow or percentage of oxygen actually in use. • Obtain a prescription for humidification if oxygen is being delivered at 4 L/min or more. • Be sure that the oxygen and humidification equipment are functioning properly. • Check the skin around the patient's ears, back of the neck, and face every 4 to 8 hours for pressure points, signs of irritation, and loss of TISSUE INTEGRITY. • Ensure that mouth care is provided every 8 hours and as needed; assess nasal and oral mucous membranes for cracks or other signs of dryness or impaired tissue integrity. • Pad the elastic band and change its position frequently to prevent skin breakdown. • Pad tubing in areas that put pressure on the skin. • Cleanse the cannula or mask by rinsing with clear, warm water every 4 to 8 hours or as needed. • Cleanse skin under the tubing, straps, and mask every 4 to 8 hours or as needed. • Lubricate the patient's nostrils, face, and lips with nonpetroleum cream to relieve the drying effects of oxygen. • Position the tubing so it does not pull on the patient's face, nose, or artificial airway. • Ensure that there is no smoking and that no candles or matches are lit in the immediate area. • Assess and document the patient's response to oxygen therapy. • Ensure that the patient has an adequate oxygen source during any periods of transport. • Provide the patient with ongoing teaching and reassurance to enhance his or her adherence to oxygen therapy.

Atherosclerosis Interventions

• Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains. • Consume low-fat dairy products, poultry, fish, legumes, nontropical (e.g., canola) vegetable oils, and nuts. • Limit intake of sweets, sugar-sweetened beverages, and red meats. • Aim for a dietary pattern that includes 5% to 6% of calories from saturated fat. • Reduce percent of calories from trans fat. The ACC/AHA also recommends that adults engage in aerobic physical activity three or four times a week to reduce LDL-C levels. Each session should last for 40 minutes on average and involve moderate-to-vigorous physical activity A class of drugs known as 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) successfully reduces total cholesterol in most patients when used for an extended period. Examples include lovastatin (Mevacor), simvastatin (Zocor), and pitavastatin (Livalo), which lower both LDL-C and triglyceride levels

The ACC and AHA publish dietary recommendations for lowering LDL-C levels (Eckel et al., 2014). These recommendations are based on the best current evidence from randomized controlled trials and include:

• Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains. • Consume low-fat dairy products, poultry, fish, legumes, nontropical (e.g., canola) vegetable oils, and nuts. • Limit intake of sweets, sugar-sweetened beverages, and red meats. • Aim for a dietary pattern that includes 5% to 6% of calories from saturated fat. • Reduce percent of calories from trans fat. These guidelines are similar to the Dietary Approaches to Stop Hypertension (DASH), which also recommend daily sodium, potassium, and fiber amounts (National Heart, Lung, and Blood Institute, 2015). Interprofessional collaboration with the dietitian to teach the patient about the types of fat content in food is encouraged. Meats and eggs contain mostly saturated fats and are high in cholesterol. Instruct patients about increasing dietary fiber to 30 g each day, which is consistent with DASH guidelines.

The teaching plan for the patient and family after surgery includes:

• Pain management • Drug therapy with reconciliation of postoperative drugs • SAFETY (e.g., understanding who to contact in case of complications, progressive increase in activity, needed assistive devices) • Prevention of infection with care and assessment of the surgical wound • Management of drains or catheters • Nutrition therapy • Follow-up with the surgeon Always ensure that the patient and family receive written discharge instructions (including medication education sheets) to follow at home. Always ensure that the patient and family understand the instructions by having them explain them in their own words.

The 2013 American College of Cardiology (ACC) and American Heart Association (AHA) Guidelines on Lifestyle Management to Reduce Cardiovascular Risk outlines evidence-based dietary and exercise practices to help lower blood pressure (Eckel et al., 2014). These guidelines are similar to the Dietary Approaches to Stop Hypertension (DASH) and include:

• Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains. • Consume low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils, and nuts. • Limit intake of sweets, sugar-sweetened beverages, and red meats. • Lower sodium intake to no more than 2400 mg per day; a limit of 1500 mg of sodium per day is preferred. • Engage in aerobic physical activity three or four times a week. Each session should last for 40 minutes on average and involve moderate-to-vigorous physical activity. In addition to following specific dietary and physical activity guidelines, teach patients ways to decrease other modifiable risk factors for hypertension, such as smoking and excessive alcohol intake.

Autoimmunity(inflammation)

• Definition: A disease where the immune cells are unable to distinguish "self" from "non self" & attacks them. Inappropriate immune response • Prognosis: Chronic, progressive, inflammation reaction- No cure • Self reactions can form against one type of cell linked to one organ/system •Genetic susceptibility-Results in different presentations of illness in family •Exposure to environmental agent-causing cross reacting immune response

The patient with COPD is expected to avoid serious respiratory infection. Indicators include that the patient consistently demonstrates these behaviors:

• Describes signs and symptoms of respiratory infection • Describes respiratory infection-monitoring procedures • Uses prevention activities such as pneumonia and influenza vaccination and crowd avoidance • Seeks medical assistance when signs of respiratory infection first appear

Management of Chest Tube Drainage Systems

• Ensure that the dressing on the chest around the tube is tight and intact. Depending on agency policy and the surgeon's preference, reinforce or change loose dressings. • Assess for difficulty breathing. • Assess breathing effectiveness by pulse oximetry. • Listen to breath sounds for each lung. • Check alignment of trachea. • Check tube insertion site for condition of the skin. Palpate area for puffiness or crackling that may indicate subcutaneous emphysema. • Observe site for signs of infection (redness, purulent drainage) or excessive bleeding. • Check to see if tube "eyelets" are visible. • Assess for pain and its location and intensity and administer drugs for pain as prescribed. • Assist patient to deep breathe, cough, perform maximal sustained inhalations, and use incentive spirometry. • Reposition the patient who reports a "burning" pain in the chest. Drainage System • Do not "strip" the chest tube. • Keep drainage system lower than the level of the patient's chest. • Keep the chest tube as straight as possible from the bed to the suction unit, avoiding kinks and dependent loops. Extra tubing can be loosely coiled on the bed. • Ensure that the chest tube is securely taped to the connector and that the connector is taped to the tubing going into the collection chamber. • Assess bubbling in the water-seal chamber; should be gentle bubbling on patient's exhalation, forceful cough, position changes. • Assess for "tidaling" (rise and fall of water in chamber three with breathing). • Check water level in the water-seal chamber and keep at the level recommended by the manufacturer. • Check water level in the suction control chamber and keep at the level prescribed by the surgeon (unless dry suction system is used). • Clamp the chest tube only for brief periods to change the drainage system or when checking for air leaks. • Check and document amount, color, and characteristics of fluid in the collection chamber as often as needed according to the patient's condition and agency policy. • Empty collection chamber or change the system before the drainage makes contact with the bottom of the tube. • When a sample of drainage is needed for culture or other laboratory test, obtain it from the chest tube; after cleaning chest tube, use a 20-gauge (or smaller) needle and draw up specimen into a syringe. Immediately Notify Physician or Rapid Response Team for: • Tracheal deviation • Sudden onset or increased intensity of dyspnea • Oxygen saturation less than 90% • Drainage greater than 70 mL/hr • Visible eyelets on chest tube • Chest tube falls out of the patient's chest (first, cover the area with dry, sterile gauze) • Chest tube disconnects from the drainage system (first, put end of tube in a container of sterile water and keep below the level of the patient's chest) • Drainage in tube stops (in the first 24 hours)

• Checklist of Nonverbal Pain Indicators (CNPI) has been tested in the acute care setting in patients with varying levels of cognitive impairment. The tool groups behavioral indicators of pain into six categories. Each category allows a score of 0 if the behavior is not observed and a 1 if the behavior occurred even briefly during activity or rest:

• Facial expression (e.g., grimacing, crying) • Verbalizations or vocalizations (e.g., screaming) • Body movements (e.g., restlessness) • Changes in interpersonal interactions • Changes in activity patterns or routines • Mental status changes (e.g., confusion, increased confusion)

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

The patient with head and neck cancer is expected to not aspirate food, gastric contents, or oral secretions into the lungs. Indicators include that the patient often or consistently demonstrates these behaviors:

• Positions self upright for eating or drinking • Selects foods according to swallowing ability • Chooses liquids and foods of proper consistency

Nonpharmacologic Interventions to Reduce Postoperative Pain and Promote Comfort

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

Prevention of Injury for the Patient Receiving Anticoagulant, Fibrinolytic, or Antiplatelet Therapy

• Handle the patient gently. • Use and teach UAP to use a lift sheet when moving and positioning the patient in bed. • Avoid IM injections and venipunctures. • When injections or venipunctures are necessary, use the smallest-gauge needle for the task. • Apply firm pressure to the needlestick site for 10 minutes or until the site no longer oozes blood. • Apply ice to areas of trauma. • Test all urine, vomitus, and stool for occult blood. • Assess IV sites at least every 4 hours for bleeding. • Instruct alert patients to notify nursing personnel immediately if any trauma occurs and if bleeding or bruising is noticed. • Avoid trauma to rectal tissues: • Do not administer enemas. • If suppositories are prescribed, lubricate liberally and administer with caution. • Instruct the patient and UAP to use an electric shaver rather than a razor. • When providing mouth care or supervising others in providing mouth care: • Use a soft-bristled toothbrush or tooth sponges. • Do not use floss. • Check to make certain that dentures fit and do not rub. • Instruct the patient not to blow the nose forcefully or insert objects into the nose. • Ensure that the patient wears shoes with firm soles whenever he or she is ambulating. • Ensure that antidotes to anticoagulation therapy are on the unit.

Acute Pain

• Has short duration • Usually has a well-defined cause • Decreases with healing • Is usually reversible • Initially serves a biologic purpose (warning sign to withdraw from painful stimuli or seek help) • When prolonged, serves no useful purpose • Ranges from mild-to-severe intensity • May be accompanied by anxiety and restlessness • When unrelieved can increase morbidity and mortality and prolong length of hospital stay

Warning Signals Associated With Lung Cancer

• Hoarseness • Change in respiratory pattern • Persistent cough or change in cough • Blood-streaked sputum • Rust-colored or purulent sputum • Frank hemoptysis • Chest pain or chest tightness • Shoulder, arm, or chest wall pain • Recurring episodes of pleural effusion, pneumonia, or bronchitis • Dyspnea • Fever associated with one or two other signs • Wheezing • Weight loss • Clubbing of the fingers

Cor Pulmonale

• Hypoxia and hypoxemia • Increasing dyspnea • Fatigue • Enlarged and tender liver • Warm, cyanotic hands and feet, with bounding pulses • Cyanotic lips • Distended neck veins • Right ventricular enlargement (hypertrophy) • Visible pulsations below the sternum • GI disturbances such as nausea or anorexia • Dependent edema • Metabolic and respiratory acidosis • Pulmonary hypertension

The patient with COPD is expected to have decreased anxiety. Indicators include that the patient consistently demonstrates these behaviors:

• Identifies factors that contribute to anxiety • Identifies activities to decrease anxiety • States that anxiety is reduced or absent

Select 2014 Evidence-Based Recommendations for the Management of High Blood Pressure in Adults (JNC 8)

• In the general population ages 60 years and older, start drug therapy to lower blood pressure (BP) at systolic blood pressure (SBP) equal to or greater than 150 mm Hg or diastolic blood pressure (DBP) equal to or greater than 90 mm Hg. The goal is to decrease BP to below 150/90. • In the general population younger than 60 years, start drug therapy to lower BP at SBP equal to or greater than 140 mm Hg or DBP equal to or greater than 90 mm Hg. The goal is to decrease BP to below 140/90. • In people ages 18 years and older with chronic kidney disease (CKD), start drug therapy to lower BP to less than 140/90. • In the general nonblack population, including those with diabetes mellitus, initial drug therapy should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). • In the general black population, including those with diabetes mellitus, initial drug therapy should include a thiazide-type diuretic or CCB. • If the goal BP is not reached within a month of treatment, increase drug dosage or add a second drug from one of the recommended classes.

Hypoxia can be caused by these factors in the patient with a tracheostomy:

• Ineffective oxygenation before, during, and after suctioning • Use of a catheter that is too large for the artificial airway • Prolonged suctioning time • Excessive suction pressure • Too frequent suctioning

symptoms of a pneumothorax (partial or complete collapse of the lung)

• Pain on the affected side that is worse at the end of inhalation and the end of exhalation • Rapid heart rate • Rapid, shallow respirations • A feeling of air hunger • Prominence of the affected side that does not move in and out with respiratory effort • Trachea slanted more to the unaffected side instead of being in the center of the neck • New onset of "nagging" cough • Cyanosis

Improve perfusion to the wound to promote wound healing:

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

Foot Care for the Patient With Peripheral Vascular Disease

• Keep your feet clean by washing them with a mild soap in room-temperature water. • Keep your feet dry, especially the ankles and between the toes. • Avoid injury to your feet and ankles. Wear comfortable, well-fitting shoes. Never go without shoes. • Keep your toenails clean and filed. Have someone cut them if you cannot see them clearly. Cut your toenails straight across. • To prevent dry, cracked skin, apply a lubricating lotion to your feet. • Prevent exposure to extreme heat or cold. Never use a heating pad on your feet. • Avoid constricting garments. • If a problem develops, see a podiatrist or health care provider. • Avoid extended pressure on your feet or ankles, such as occurs when you lean against something.

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 L (quarts) of nonalcoholic fluids each day (unless fluid restrictions are needed because of another health problem).

To prevent DVT, unfractionated heparin may be given in low doses subcutaneously for high-risk patients, especially after orthopedic surgery. Alternatives to unfractionated heparin include:

• Low-molecular-weight heparin (e.g., enoxaparin [Lovenox]) (drug class of choice after orthopedic surgery) • Novel oral anticoagulants (dabigatran [Pradaxa], rivaroxaban [Xarelto], apixaban, [Eliquis], edoxaban [Savaysa]) • Warfarin (Coumadin, Warfilone)

Emergency Care of a Patient With an Anterior Nosebleed

• Maintain Standard Precautions or Body Substance Precautions. • Position the patient upright and leaning forward to prevent blood from entering the stomach and possible aspiration. • Reassure the patient and attempt to keep him or her quiet to reduce anxiety and blood pressure. • Apply direct lateral pressure to the nose for 10 minutes and apply ice or cool compresses to the nose and face if possible. • If nasal packing is necessary, loosely pack both nares with gauze or nasal tampons. • To prevent rebleeding from dislodging clots, instruct the patient to not blow the nose for 24 hours after the bleeding stops. • Seek medical assistance if these measures are ineffective or if the bleeding occurs frequently.

Evaluate the care of the patient with head and neck cancer based on the identified priority patient problems. The expected outcomes are that the patient:

• Maintains a patent airway • Performs self-care of the artificial airway and wound • Performs ADLs independently or with minimal assistance • Attains or maintains adequate NUTRITION • Does not aspirate gastric contents or food • Engages in desired social interactions

The patient with COPD is expected to increase activity to a level acceptable to him or her. Indicators include that the patient:

• Maintains his or her baseline SpO2 with activity • Performs ADLs with no or minimal assistance • Participates in family, work, or social activities as desired

The patient with pneumonia is expected to have adequate GAS EXCHANGE and oxygenation. Indicators of adequacy are:

• Maintenance of SaO2 of at least 95% or in the patient's normal range • Absence of crackles and wheezes on auscultation • Absence of cyanosis • Maintenance of cognitive orientation

The postoperative patient is expected to attain or maintain optimal COMFORT levels. Indicators include:

• Patient report that pain is controlled • Absence of physiologic indicators of acute pain (increased heart rate and blood pressure) • Absence of behavioral indicators of pain (e.g., facial grimacing, teeth clenching, guarding, rubbing the painful area) • Willingness to ambulate and participate in self-care

Patient and Family Education: Preparing for Self-Management Smoking Cessation

• Make a list of the reasons you want to stop smoking (e.g., your health and the health of those around you, saving money, social reasons). • Set a date to stop smoking and keep it. Decide whether you are going to begin to cut down on the amount you smoke or are going to stop "cold turkey." Whichever way you decide to do it, keep this important date! • Ask for help from those around you. Find someone who wants to quit smoking and "buddy up" for support. Look for assistance in your community, such as formal smoking-cessation programs, counselors, and certified acupuncture specialists or hypnotists. • Consult your health care provider about nicotine replacement therapy (e.g., patch, gum) or other pharmacologic therapy to assist in smoking cessation. • Remove ashtrays and lighters from your view. • Talk to yourself! Remind yourself of all the reasons you want to quit. • Think of a way to reward yourself with the money you save from not smoking for a year. • Avoid places that might tempt you to smoke. If you are used to having a cigarette after meals, get up from the table as soon as you are finished eating. Think of new things to do at times when you used to smoke (e.g., taking a walk, exercising, calling a friend). • Find activities that keep your hands busy: needlework, painting, gardening, even holding a pencil. • Take five deep breaths of clean, fresh air through your nose and out your mouth if you feel the urge to smoke. • Keep plenty of healthy, low-calorie snacks, such as fruits and vegetables, on hand to nibble on. Try sugarless gum or mints as a substitute for tobacco. • Drink at least eight glasses of water each day. • Begin an exercise program with the approval of your primary health care provider. Be aware of the positive, healthy changes in your body since you stopped smoking. • List the many reasons why you are glad that you quit. Keep the list handy as a reminder of the positive things you are doing for yourself. • If you have a cigarette, think about the conditions that caused you to light it. Try and think of a strategy to avoid that (or those) conditions. • Don't beat yourself up for backsliding; just face the next day as a new day. • Think of each day without tobacco as a major accomplishment. It is!

Common Causes of Ventilatory Failure

• Neuromuscular disorders: • Myasthenia gravis • Guillain-Barré syndrome • Poliomyelitis • Spinal cord injuries affecting nerves to intercostal muscles • Central nervous system dysfunction: • Stroke • Increased intracranial pressure • Meningitis • Chemical depression: • Opioid analgesics, sedatives, anesthetics • Kyphoscoliosis • Massive obesity • Sleep apnea • External obstruction/constriction • Airway disease: • Chronic obstructive pulmonary disease (COPD), asthma • Ventilation-perfusion (V̇/Q̇)mismatch: • Pulmonary embolism • Pneumothorax • Acute respiratory distress syndrome (ARDS) • Amyloidosis • Pulmonary edema • Interstitial fibrosis

Focused Assessment The Patient With a Tracheostomy

• Note the quality, pattern, and rate of breathing: • Within patient's baseline? • Tachypnea can indicate hypoxia. • Dyspnea can indicate secretions in the airway. • Assess for any cyanosis, especially around the lips, which could indicate hypoxia. • Check the patient's pulse oximetry reading. • If oxygen is prescribed, is the patient receiving the correct amount, with the correct equipment and humidification? • Assess the tracheostomy site: • Note the color, consistency, and amount of secretions in the tube or externally. • If the tracheostomy is sutured in place, is there any redness, swelling, or drainage from suture sites? • If the tracheostomy is secured with ties, what is the condition of the ties? Are they moist with secretions or perspiration? Are the secretions dried on the ties? Is the tie secure? • Assess the condition of the skin around the tracheostomy and neck for tissue integrity. Be sure to check underneath the neck for secretions that may have drained to the back. Check for any skin breakdown related to pressure from the ties or related to excess secretions. • Assess behind the faceplate for the size of the space between the outer cannula and the patient's tissue. Are any secretions collected in this area? • If the tube is cuffed, check cuff pressure. • Auscultate the lungs. • Are a second (emergency) tracheostomy tube and obturator available?

Nursing Focus on the Older Adult Beliefs About Pain

• Older adults tend to report pain less often than younger adults, which frequently results in members of the health care team administering suboptimal analgesics and doses. The failure of older adults to report pain may be related to common beliefs and concerns they have about pain and reporting it such as: • Pain is an inevitable consequence of aging and little can be done to relieve it. • Expressing pain is unacceptable or is a sign of weakness. • Reporting pain will result in being labeled as a "bad" patient or a "complainer." • Nurses and physicians are too busy to listen to reports of pain. • Pain signifies a serious illness or impending death. • Be aware of the common beliefs of older patients regarding pain and its management and correct misconceptions to help prevent barriers to achieving optimal pain relief. • Nurses and other caregivers can overcome their reluctance to administer prescribed analgesics in adequate doses by following the principles of pain management in older people

Proper positioning is ensured by assessing for:

• Optimal exposure of the operative site and IV line • Adequate access to the patient for the anesthesia provider • Interference with circulation and breathing • Anatomic alignment • Protection of skeletal and neuromuscular structures • Patient comfort, SAFETY, and dignity

Warning Signs of Head and Neck Cancer

• Pain • Lump in the mouth, throat, or neck • Difficulty swallowing • Color changes in the mouth or tongue to red, white, gray, dark brown, or black • Oral lesion or sore that does not heal in 2 weeks • Persistent or unexplained oral bleeding • Numbness of the mouth, lips, or face • Change in the fit of dentures • Burning sensation when drinking citrus juices or hot liquids • Persistent, unilateral ear pain • Hoarseness or change in voice quality • Persistent or recurrent sore throat • Shortness of breath • Anorexia and weight loss

Emergency Care of the Patient Experiencing an Opioid Overdose

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

The patient is expected to have return of intestinal peristalsis after surgery as indicated by:

• Presence of active bowel sounds in all four abdominal quadrants • Passage of flatus and/or stool • No abdominal distention or rigidity

Major risk factors for VTE leading to PE are:

• Prolonged immobility • Central venous catheters • Surgery • Obesity • Advancing age • Conditions that increase blood CLOTTING • History of thromboembolism

Hypersensitivity ReactionsType I

• Rapid hypersensitivity (most common type) •Increased production of IgE • Causes mast cells to release vasoactive substances, especially histamine causing massive vasodilation •Primary phase- Re-exposure, histamine release, inflammation, 10 min •Secondary phase-Other cells stimulated, ↑ symptoms & lasts longer •Examples: allergic asthma, angioedema, anaphylaxis, urticaria (hives), atopic dermatitis

Hypersensitivity ReactionsType IV

• Reaction from T-lymphocyte (T-cell) • Sensitized T-cell comes in contact with antigen (from prev. exposure) • Reaction not immediate- hours/days after exposure causing inflammation • S/S- Edema, induration, rash, dermatitis •Examples: Poison ivy, Positive TB skin tests, Graft vs. Host rejection, insect stings w/local reaction

Nursing Focus on the Older Adult Prevalence of Pain

• Recognize that older adults are at high risk for undertreated pain and those with cognitive impairment are at even higher risk. • Common caregiver and health care team misconceptions such as that pain sensitivity decreases with aging and older adults cannot tolerate analgesics without significant adverse effects contribute to the undertreatment of pain in older adults.

Pneumothorax and Hemothorax Assessment

• Reduced (or absent) breath sounds of the affected side on auscultation • Hyperresonance on percussion • Prominence of the involved side of the chest, which moves poorly with respirations • When severe, deviation of the trachea away from the midline and side of injury toward the unaffected side (indicating pushing of tissues to the unaffected side [a mediastinal shift] from increasing pressure within the injured side) For tension pneumothorax, additional assessment findings also may include: • Extreme respiratory distress and cyanosis • Distended neck veins • Hemodynamic instability With a hemothorax, percussion on the involved side produces a dull sound. In addition to symptoms, chest x-rays, CT scans, or ultrasonography may be used for diagnosis of any type of pneumothorax or hemothorax.

Nursing Interventions to Prevent and Treat Selected Opioid Side Effects: Sedation

• Remember that sedation precedes opioid-induced respiratory depression; identify patient and iatrogenic risk factors and monitor sedation level and respiratory status frequently during the first 24 hours of opioid therapy. • Use a simple sedation scale to monitor for unwanted sedation (see Table 4-8). • If excessive sedation is detected, reduce opioid dose to prevent respiratory depression. • Eliminate unnecessary sedating drugs such as antihistamines, anxiolytics, muscle relaxants, and hypnotics. If it is necessary to administer these drugs during opioid therapy, monitor sedation and respiratory status closely. • Reassure patients taking long-term opioid therapy that tolerance to this side effect develops with regular daily opioid doses. • Be aware that stimulants such as caffeine may counteract opioid-induced sedation. • Consider switching to another opioid for unresolved excessive sedation during long-term opioid therapy.

Nursing Focus on the Older Adult Considerations for Cognitively Impaired Patient

• Remember to "assume that pain is present" in patients with diseases and conditions or procedures commonly associated with pain (see discussion below on analgesic trial). • If the patient is unable to provide self-report, look for behaviors that may indicate the presence of pain. • Someone who knows the patient well such as a family member or caregiver may be helpful in identifying behaviors that might indicate pain. Do not ask others to rate pain intensity and do not attempt to rate it yourself. Only the patient knows how severe the pain is; if he or she cannot rate or describe the intensity, the exact intensity is unknown. • Assess using a reliable and valid behavioral pain assessment tool. • Remember that behavioral tools tell us that pain might be present and provide a reference point to help determine the effectiveness of interventions, but the scores on behavioral tools have not been correlated with the ratings on pain intensity scales. A behavioral score is not a pain intensity rating. • Use the same behavioral assessment tool each time pain is assessed. • Consider an analgesic trial to help determine the presence of pain and to establish an ongoing treatment plan in patients who are thought to have pain. This involves the administration of a low-dose analgesic; changes or decreases in the intensity of behaviors indicate that pain may be the cause of the behaviors. Doses should be increased, or additional analgesics added as appropriate.

The nurse evaluates the care of the patient during surgery based on the identified priority patient problems. The expected outcomes include:

• Safe anesthesia care provided without complications • Remains injury free related to surgical positioning or equipment (no skin tears, bruises, redness, or other injury over pressure points) • Remains free of skin or tissue contamination and infection during surgery • Maintains normal thermoregulation and body temperature

Emergency Care of the Patient Experiencing a Benzodiazepine Overdose

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

Using a Peak Flow Meter

• Set the peak flow meter 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. Teach the patient that, if a red zone reading occurs when using the peak flow meter, to immediately use the reliever drugs and seek emergency help.

Common Causes of Acute Lung Injury

• Shock • Trauma • Serious nervous system injury • Pancreatitis • Fat and amniotic fluid emboli • Pulmonary infections • Sepsis • Inhalation of toxic gases (smoke, oxygen) • Pulmonary aspiration (especially of stomach contents) • Drug ingestion (e.g., heroin, opioids, aspirin) • Hemolytic disorders • Multiple blood transfusions • Cardiopulmonary bypass • Submersion in water with water aspiration (especially in fresh water)

Respiratory Assessment: Patient History

• Smoking history • Childhood illnesses: • Asthma • Pneumonia • Communicable diseases • Hay fever • Allergies • Eczema • Frequent colds • Croup • Cystic fibrosis • Adult illnesses: • Pneumonia • Sinusitis • Tuberculosis • HIV and AIDS • Lung disease such as emphysema and sarcoidosis • Diabetes • Hypertension • Heart disease • Influenza, pneumococcal (Pneumovax), and BCG vaccinations • Surgeries of the upper or lower respiratory system • Injuries to the upper or lower respiratory system • Hospitalizations • Date of last chest x-ray, pulmonary function test, tuberculin test, or other diagnostic tests and results • Recent weight loss • Night sweats • Sleep disturbances • Lung disease and condition of family members • Geographic areas of recent travel • Occupation and leisure activities • Drug use • Allergies

Emergency Care of the Patient With Malignant Hyperthermia

• Stop all volatile inhalation anesthetic agents and succinylcholine. • If an endotracheal tube (ET) is not already in place, intubate immediately. • Ventilate the patient with 100% oxygen at the highest possible flow rate to flush anesthetics and lower end-tidal carbon dioxide. • Administer dantrolene sodium (Dantrium) IV at a dose of 2 to 3 mg/kg. Repeat as needed. • If possible, terminate surgery. If termination is not possible, maintain general anesthesia with IV anesthetic agents that do not trigger malignant hyperthermia (MH) (IV sedatives, narcotics, amnestics and nondepolarizing neuromuscular blockers). • 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 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. Avoid calcium channel blockers. • Administer intravenous 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 Hyperthermia Association of the United States: (800) 644-9737.

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, vendors) • All available options and the benefits and 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 risks, benefits, and alternatives to the use of blood or blood products during the procedure

Asthma Self management

• The prescribed daily controller drug(s) schedule and prescribed reliever drug directions • Patient-specific daily asthma control assessment questions • Directions for adjusting the daily controller drug schedule • When to contact the primary health care provider (in addition to regularly scheduled visits) • Emergency actions to take when asthma is not responding to controller and reliever drugs

Factors influencing the positioning process include:

• The surgical site (procedure being performed) • The age, weight, and size of the patient • The anesthetic delivery technique • Pain on movement (conscious patient) • The surgeon's preference • Any pulmonary, skeletal, or muscular limitations such as arthritis, joint replacements, emphysema, or implanted devices

the adults who are at greatest risk for development of TB are:

• Those in constant, frequent contact with an untreated person • Those who have reduced IMMUNITY or HIV • Adults who live in crowded areas such as long-term care facilities, prisons, homeless shelters, and mental health facilities • Older homeless adults • Abusers of injection drugs or alcohol • Lower socioeconomic groups • Foreign immigrants

Postoperative Hand-off Report

• Type and extent of the surgical procedure • Type of anesthesia and length of time the patient was under anesthesia • Allergies (especially to latex or drugs) • Any health problems or pathophysiologic conditions • Any relevant events/complications during anesthesia or surgery such as a traumatic intubation • If intraoperative complications, how were they managed and patient responses (e.g., laboratory values, excessive blood loss, injuries) • Status of vital signs, including temperature and oxygen saturation • Intake and output, including current IV fluid administration and estimated blood loss • Type and amount of IV fluids or blood products • Medications administered and when last dose of pain medication given • When the next dose of medications is due, especially antibiotics, cardiac drugs • Primary language, any sensory impairments, any communication difficulties • Special requests that were verbalized by the patient before surgery, including communications with family • Preoperative and intraoperative respiratory function and dysfunction • Location and type of incisions, dressings, catheters, tubes, drains, or packing • Prosthetic devices • Joint or limb immobility while in the operating room, especially in the older patient • Other intraoperative positioning that may be relevant in the postoperative phase

Nursing Interventions to Prevent and Treat Selected Opioid Side Effects: Nausea/Vomiting

• Use a multimodal antiemetic preventive approach (e.g., dexamethasone plus ondansetron in moderate- to high-risk patients). • Assess cause of nausea and eliminate contributing factors if possible. • Reduce opioid dose if possible. • Reassure patients taking long-term opioid therapy that tolerance to this side effect develops with regular daily opioid doses. • Treat with antiemetic drug as prescribed. • Consider switching to another opioid for unresolved N/V.

Hypersensitivity reactionsType III

•Excess antigens/antibodies formed causing immune complexes to form •Immune complexes deposit in blood vessel walls & results in complement release •Reaction localized, evolves over several hours. Blood vessel damage=Hemorrhage, necrosis. •Complexes lodge in small blood vessels of kidneys, joints, tissue = inflammation •Examples: Serum Sickness, Systemic Lupus Erythematosus, Rheumatoid Arthritis •Immune complex: molecule formed from antigen/antibody binding=soluble antigen •Compliment: (pg 294)- Cascade response attracts other cells & enhances immune response

Nursing Focus on the Older Adult Management of Pain

• Use a multimodal approach that combines analgesics with different underlying mechanisms with the desired outcome of achieving optimal pain relief with lower doses than would be possible with a single analgesic; lower doses result in fewer side effects. • Consider the type of pain and begin therapy with the first-line analgesics that are recommended for that type of pain. • Do not give meperidine to older adults because most have decreased renal function and are unable to efficiently eliminate its central nervous system (CNS)-toxic metabolite normeperidine. • Use around-the-clock (ATC) dosing of analgesics for pain that is of a continuous nature (e.g., chronic osteoarthritis or cancer pain; chronic neuropathic pain, first 24 to 48 hours after surgery). • Use as needed (PRN) dosing for intermittent pain and before painful activities such as before ambulation and physical therapy. • Be aware of the main side effects of the analgesics that are administered and that they may be more likely to occur or be more severe in older than in younger adults. • Start low and go slow with drug dosing; increase doses to achieve adequate analgesia based on patient's response to the previous dose. • Teach the patient and family or other caregiver about the pain management plan (analgesics and nonpharmacologic strategies) and when to notify the primary health care provider for unrelieved pain or unmanageable or intolerable drug side effects. • To promote adherence to the pain management plan in the home setting, suggest using a pillbox to organize each day's medications and keeping a diary to identify times of the day or activities that increase pain. The diary can be presented to the primary health care provider who can use it to make necessary adjustments in the treatment plan.

Preventing Injury and Bleeding During the time you are taking anticoagulants:

• Use an electric shaver. • Use a soft-bristled toothbrush and do not floss. • Do not have dental work performed without consulting your health care provider. • Do not take aspirin or any aspirin-containing products. Read the label to be sure that the product does not contain aspirin or salicylates. • Do not participate in contact sports or any activity likely to result in your being bumped, scratched, or scraped. • If you are bumped, apply ice to the site for at least 1 hour. • Avoid hard foods that would scrape the inside of your mouth. • Eat warm, cool, or cold foods to avoid burning your mouth. • Check your skin and mouth daily for bruises, swelling, or areas with small, reddish-purple marks that may indicate bleeding. • Notify your health care provider if you: • Are injured and persistent bleeding results • Have excessive menstrual bleeding • See blood in your urine or bowel movement • Avoid anal intercourse. • Take a stool softener to prevent straining during a bowel movement. • Do not use enemas or rectal suppositories. • Do not wear clothing or shoes that are tight or that rub. • Avoid blowing your nose forcefully or placing objects in your nose. If you must blow your nose, do so gently without blocking either nasal passage. • Avoid playing musical instruments that raise the pressure inside your head, such as brass wind instruments and woodwinds or reed instruments. • Keep all appointments for laboratory tests.

Chronic Pain

• Usually lasts longer than 3 months • May or may not have well-defined cause • Usually begins gradually and persists • Serves no useful purpose • Ranges from mild-to-severe intensity • Often accompanied by multiple quality-of-life and functional adverse effects, including depression; fatigue; financial burden; and increased dependence on family, friends, and the health care system • Can impact the quality of life of family members and friends

The patient with head and neck cancer is expected to have decreased anxiety. Indicators include that the patient often or consistently demonstrates:

• Verbalization of reduced anxiety • Absence of distress, irritability, and facial tension • Effective use of coping strategies

The patient with head and neck cancer is expected to accept body image changes. Indicators include that the patient often or consistently demonstrates:

• Willingness to touch and care for the affected body part • Willingness to use strategies to enhance appearance • Interaction with visitors, staff, and family members