NUR308 Quiz I

Patient's Using and Incentive Spirometer - purpose - how to use - why do we use it - DVT/ SCD/ other exercises

- Before surgery teach patient about the incentive spirometer. - To prevent atelectasis, or collapse of the alveoli, which instead of being open it is collapsed. - Incentive spirometer, you inhale hold it and exhale. - It should be used every hour at least 10-20 times. - The goal is the get the ball up higher. - Also encourage the pt for coughing prior to surgery. - The greatest risk after surgery is a DVT. - Teach the pt about SCD (Sequential compression device) placement. - Encourage pt for early ambulation post surgery. - Pt can also be taught isometric exercises, gluteal tightening, dorsiflexion or plantar flexion of the foot.

CVC Management: Post-Insertion - infection, dislodgment, occlusion, air embolus (steps to take to prevent) - Removal Considerations

- Infection- sterile dressing change - Dislodgement - Occlusion - First aspirate. You should always get blood return with a CVC. Not true for a peripheral cath. Attach syringe with NS, first pull back a little, see some blood, then flush. -- If you do not get blood back and you couldn't flush, do not force it. It can cause an embolism. - Air embolus -- Prevent air embolism by priming the line and make sure there is no air in the syringe. Removal Considerations - Turn everything off. Remove the sutured wings. Apply pressure. Apply pressure dressing at site. Before throwing it away, make sure cath is intact.

Central Venous Catheters: Nontunneled - most common used vessel - how to insert catheter -- pt position -- solution to clean skin -- skin prep -- type of needle used to insert -- site needle is inserted -- catheter advances over a _______ -- once in place catheter is _____ -- what type of dressing -- reason for insertion -- role/precautions of the nurse

- Most common used vessel is subclavian vein. Preferred. - Other places, but not recommended: jugular or femoral vein. - The patient is placed in supine position, site is cleansed (chlorhexidine) - skin is anesthetized, a large bore needle is inserted beneath the clavicle. - The catheter is advanced over a guidewire. The catheter is sutured. A sterile transparent dressing is applied. • Inserted for someone who needs fluids and a large amount of fluids. Central Venous Catheter - RN only assists. You need to have a mask on while assisting and while changing the dressing.

Fluid Volume Deficit - relative _______ - BUN (if this is elevated what do you check next? If _____ in not elevated then pt should only be experiencing FVD) - Hct - HgB - osmolality - glucose - protein

- Relative hypernatremia - Elevated BUN (normal 10-20), if elevated check their creatinine, which should be normal if it is only related to FVD - Elevated hematocrit, hgb, osmolality, glucose, protein Creatinine: 0.8 to 1.2 mg/dL HcT: (men) 38.8-50%; (women) 39.9-44.5% HgB: (men) 135-175 g/L; (women) 120-155g/L Serum osmolality: 285-295 mOsm/kg Glucose: 64 to 100 mg/dL Serum protein: 6 to 8 g/dl (albumin: 3.5-5.0)

Infected IV Site - s+s - actions to take - what to do for a CVC

- red, swollen, warm, tender, exudates, fever, WBC's. - Notify the provider, they will order blood cultures. -With a central venous cath, tip of cath will be removed and sent to lab to see if the infection is systemic or only in the cath.

Surgical Risk in Elderly - breathing (dec _____ _____) - renal (dec _ _ _) - cardiac (dec ___, inc ___) - nutrition

1. Decreased vital capacity. Anesthesia is delivered in gas. If they decrease vital capacity, the anesthesia will remain in the body longer 2. Decreased GFR - adjust medications because meds will take longer to be excreted 3. Decreased CO, HTN 4. Malnutrition - decreased wound healing

Deficient Knowledge Interventions: Pre-Operative Assessment - 2 reasons why nurse should obtain an assessment: - allergies (food, food that correlates to latex, food that correlates to iodine, food that correlates to propofol) - CAGE/alcohol (what will they prescribe) - st. johns wart (what does it treat, what effect does it have?) - Ginger, garlic, ginseng and vitamin E (what do these increase the risk of)

1. To identify risk in order to prevent complications 2. To obtain a baseline, so that you have a comparison post operatively Allergies - latex, medications, OTC, prescribed, foods such as shellfish/iodine - Any reactions to cleaning products chlorhexidine, betadine, steri-strips during previous surgeries. - Banana/kiwi/strawberries/avocado allergy -> - Povidone-iodine (betadine) = shellfish allergy. - Propofol (diprivan) = egg/peanut/soy allergy Include alcohol as well. Use CAGE (Cut Down, Annoyed, Guilty and Eye Opener ) - Do you drink alcohol? How much? How many per day? When was the last time you had a drink? (this one is critical, because they are likely to have DT's (delirium/tremors) and are at high risk for withdrawal. They can prescribe Librium in the hospital or whiskey, which requires a hx. Medications - Herbs/ Supplements - Antidotal evidence and not well controlled. A few to be aware of: 1. St. John's Wart, used to tx depression. We need to be aware of it because it prolongs the effects of anesthesia. 2. Ginger garlic ginseng and vitamin E - increase the risk of bleeding. They need to stop taking the supplements several weeks prior to surgery - Cultural/religious considerations - Jehovah's witness do not want blood transfusions - Social Support - Functional assessment

Hypokalemia - etiology -- actual/absolute potassium depletion (definition, examples) -- relative (definition, treatment that may lead to hypokalemia) - respiratory effects - muscle effects (special test) - cardiac (on ecg) - GI

Actual/absolute potassium depletion: occurs when potassium loss is excessive or when potassium intake is not adequate to match normal potassium loss. • Decreased intake: IV fluids • Increased loss: diuretics (loops and thiazides), digitalis use bc in pt's taking digoxin, hypokalemia increases the sensitivity of cardiac muscle to the drug and may result in digoxin toxicity, even when dig levels are within the therapeutic range. Relative hypokalemia: occurs when total body potassium levels are normal but the potassium distribution between fluid spaces is abnormal or it is diluted by excess water. • Shift of potassium into cells: remember the tx for DKA is to give regular insulin IV, resulting in hypokalemia • Respiratory insufficiency is a major cause of death in hypokalemia pt's because of respiratory muscle weakness. • # 1 cause of death w HYPOkalemia is respiratory in nature- weakness including intercostal nerves and diaphragm dysfunction • Also decreased DTR's. • Can also have cardiac changes. EKG changes: Prominent U wave • GI smooth muscle contractions are decreased. Paralytic ileus.

Peripheral IV Access - advantages - disadvantages

Advantages: • Easily inserted • Low cost • Minimal complications • Use: Short term - 72-96 hours, typically can last 3 days Disadvantages: • Use is limited to certain fluids/meds - don't give vesicant drugs (drugs that cause severe tissue damage if they escape into the subcutaneous tissue "extravastation") or hyperosmolar fluids >600 mOsm/L through a peripheral line • Local tissue injury - infiltration (leakage of a non-vesicant IV solution or medication into the extravascular tissue) • Easily clotted

Anesthesia / General Anesthesia

Anesthesia • Induced state of partial or total loss of sensation, occurring with or without loss of consciousness • Used to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and, in some cases, achieve a controlled level of unconsciousness General Anesthesia • Reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of the central nervous system • Involves a single agent or a combination of agents • Delivered as a combination through inhaled gasses and IV. The goal is reversible LOC. Will lead to amnesia and result in analgesia, because it's suppressing the central nervous system. Along with it we use neuromuscular blockers given IV. Any one requiring general anesthesia will need an advanced airway, concern for diaphragm. • Pro: LOC. In other's, such as seizure activity we do not want LOC. It will also immobilize the pt, not wanted in certain procedures.

American Nurses Association (ANA): Medical-Surgical Nursing - definition - formally recognizes MedSurge as a __________ -Why should you join specialty organizations?

Area of nursing practice concerned with the care of adults with predicted or existing physiologic alterations, trauma, or disability. The ANA has formally recognized medical-surgical nursing as a specialty; focused practice areas are seen as subspecialties 1. Identify best practices: ex evidence based practices for VAP tx 2. Allow the nurse to obtain certification

Intravenous Therapy: Alternative Sites for Infusion - arterial therapy -- used to monitor ___; to draw ___; to assess ____; which artery used for chemo infusion? - intraperitoneal infusion -- what tx used for? where is fluid infused? what 3 mechanisms occur in tx? - subcutaneous infusion -- most common pt that uses this? other situations- hospice, palliative care - intraspinal -- when are they used - intraosseous therapy -- which personnel/ settings use it? why?

Arterial therapy - A line. Used to monitor blood pressure. Used to draw blood, ABG. Used to administer chemo. -- Intrahepatic artery chemo. Chemo infused through hepatic artery. Number one concern is bleeding. Intraperitoneal infusion - a type of dialysis. Fluid infused to abdomen, peritoneum and then removed. Use osmosis, diffusion and filtration. Subcutaneous infusion - typically type 1 diabetics, with an insulin pump. Also used in hospice situations. Ex. Hospice pt with a DNR, you can give a bolus subq. Also used for pain meds. Beneficial for palliative care patients who cannot tolerate oral meds, when IM injections are too painful, or when vascular access is not available or is too difficult to obtain. Intraspinal infusion - related to anesthesia, epidurals and subdurals Intraosseous therapy - used by first responders, in a trauma room, etc. when they cannot get an IV started. Inserted into the bone into the rich vascular network in the red marrow of bones. Most common site is the proximal tibia.

Infection Control Measures: Principles of Infection Control - aseptic technique - infection prevention and VAD's -- site prepared with what proper solution -- how often to change dressings on PICC lines -- reduce _______ ______ into a closed IV system -- avoid what instrument

Aseptic technique • Same as sterile technique Infection prevention and VADs • Site preparation with appropriate antimicrobial • Sterile dressings - every 5-7 days the transparent dressings on PICC lines are changed. • Change fluid administration sets as recommended • Reduce multiple entries into a closed IV system • In capped systems ensure proper use of prep solutions • Avoid the use of stopcocks (valve)

Factors to Decrease Fluid Volume Overload - ANP (what is it/where is it stored/released) - Angiotensin II does what - Drop in what vital signs - Increase in ___ to dec. blood osmolality - Monitored in what type of patient's

Atrial Natriuretic Peptide: ANP • Amino acid peptide synthesized, stored and released by atria and ventricular cells • Angiotensin II stimulation, increased atrial pressure, increased volume expansion (Stimulated and released when there is a stretching of the atria) • blood pressure & volume drop (ANP is opposite to RAAS, it decreases blood volume and decreases BP) o GFR is increased, causing decreased blood osmolarity • Monitored in heart failure pt's

Immediate Thermoregulation Complications

Both hypothermia and hyperthermia are associated with physiologic alterations that may interfere with immediate postoperative recovery. • Hypothermia: Shivering increases oxygen demand up to 400%, impairs coagulation, and causes decreased cerebral blood flow. Compensatory mechanism, increases metabolic demand which can cause a mismatch in oxygen suppy. That's why we use warming devices to conserve heat. • Hyperthermia: This can be caused by an infectious process, sepsis, or malignant hyperthermia (might occur or recur as late as 24-72 hours after surgery). Malignant hyperthermia has also been found 72 hours post op. If not related to MH, can be related to infection.

"C" in SPICES - causes (2 important); older adult has a higher risk for one over the other-what can increase % at getting one of the pathophysiologic states? - assessment (main concern)

Confusion Causes: Dementia - irreversible, chronic, develops months to years, over a longer period of time, most associated with Alzheimer's. Delirium - an acute change in cognitive function, develops hours to days. The older adult has a higher risk of delirium. It is not a normal physiological change. • increased risk of delirium with isolation, change in familial surroundings, lack of sleep, medications (ex. rantidine zantac increases delirium in older adults), sundown (as light dissipates it worsens the delirium) o Assessment: We have to have a baseline assessment to see if there is a change in cognitive function Our main concern with these both disorders is safety

Common IV Sites - don't - do

DON'T • Not lower extremities, due to increased risk for DVT and infiltration. • Should not be in the arteries. • For a pt who has had a radical mastectomy, the lymph nodes have also been removed. Do not place in that extremity. • Do not place in extremity where there is an AV graft or an AV fistula. • Do not place in side with weakness post stroke. • Avoid areas of flexion or movement, bifurcation. DO: • Start in the upper extremity (not the wrist). • Start in non-dominant hand. • Start more distal to the pt. If it infiltrates distally you can move up the arm. FR usually has an antecubital IV.

Hypocalcemia - etiology -- decreased ionized calcium (in which pH state? what in blood transfusion dec. calcium release?) -- excessive loss (what disease) -- reciprocal relationship with which element - result -- muscle (2 hallmark; 1 dangerous sign)

Decreased ionized calcium: -- when we are alkalotic more calcium binds to albumin, so we have less free ionized calcium -- Citrate in blood transfusion packs binds to calcium, decreasing available calcium because it is a calcium chelator or binder. -- Excessive loss: with renal disease -- Reciprocal relationship with phosphorous. Renal disease pt's have high phosphorous and low Ca. Results in tetany, and numbness and tingly: chvostek (facial muscle response) and trosseau's sign (palmar flexion) More dangerous is laryngeal spasm

Management of Fluid Volume Deficit Patient Assessment - I/O - earliest indicator of FVD in an older adult - HR/rhythm - BP - RR - Urine output - weight **which amounts in mL match with lbs lost/gained**

Decreased skin turgor, and dry mucous membranes - skin turgor is less reliable because of poor skin turgor resulting from the loss of elastic tissue and increased skin dryness from the loss of tissue fluid with aging. In dehydration, turgor is poor, tent remaining for minutes after pinching the skin. •Altered mental status, (ex. Can be someone who is relatively calm and now becomes agitated) ---The first/earliest indicator of FVD in the older adult is cognitive changes, it is NOT skin turgor. Confusion is more common among older adults and may be the first indication of a fluid imbalance. • tachycardia - HR increases in an attempt to maintain BP with less blood volume • weak and thready pulse • hypotension • tachypnea - RR increases because there is reduced perfusion and oxygenation with decreased blood volume • low urine output • weight loss o 1L of fluid is = 1 kg of weight = 2.2 lbs. Changes in daily weights are the best indicators of fluid losses or gains. A weight change of 1 lb. corresponds to a fluid volume change of about 500 mL.

Dehisence and Aviceration

Dehisence and Aviceration (body part portrudes), can occur starting at day 3 post-op, because the pt is more active. Risks are coughing without splinting. Nausea and vomiting can also increase the risk. If pt has an aviceration, pt will heal with secondary intention (wound healing will be delayed, need to be packed, increasing risk for infection). If aviceration, do not push it back in. Put a moist sterile dressing on it and cover it while MD comes in. Take their vital signs.

CVC Site: Dressing Changes - function - type of dressings - time between changes (transparent, tape and gauze)

Dressings function to secure the catheter and protect from site contamination Dressing changes Transparent semi-permeable membrane type -- Change at least weekly -- Becomes tape and gauze dressing if gauze is present Tape and gauze -- Change every 24-48 hours - changed more frequently if gauze was used. Securement devices -- Change at least weekly Dressings should be individualized to the needs of the patient

Treatment of Hyperkalemia - emergency situations (first line tx/type of solution, what is used to correct metabolic acidosis, what will stabalize the heart?) - non-emergent (first-line, o/t drug) - treat cause

Emergency Situations: First line tx: Glucose & Insulin IV (hypertonic) -- cause potassium to move back into the cell, this is the only IV insulin we give IV, it will also drop your blood glucose level, that's why we give it with D50. -- Movement of potassium from the ECF to the ICF can help reduce serum potassium levels temporarily. -- Potassium movement into the cells is enhanced by insulin. Insulin increases the activity of the sodium-potassium pumps, which move potassium from the ECF into the cell. Sodium Bicarb -- used to help correct metabolic acidosis Calcium Chloride -- will stabilize the heart Additional Treatments: Non-emergent First line: Sodium polystyrene sulfonate (Kayexalate) -- promotes the excretion of potassium in the stool -- This therapy takes hours to reduce potassium levels. (IF potassium levels are dangerously high, dialysis is needed) Sorbitol --gives you gas and diarrhea Treat Cause- if it is due to renal failure, perform dialysis

"E" in SPICES - causes - assessment (questions to ask pt; tool to use for assessment)

Evidence of Falls o Causes: see delirium causes o Assessment: do you use any assistive devices? Do you have a hx of falls? A recent hx of falling is the single most important predictor for falls. Target assessment for risk of falls in older patients is the MORSE FALL SCALE. It helps the nurse focus on factors that increase an older person's risk for falling.

Hyperkalemia - etiology -- excess intake (due to _____) -- decreased loss (common cause; pharm; adrenal insufficiency) -- shift of potassium (associated with; example) -- key finding (muscle, heart, causes ____ on ECG; number one cause of death is __)

Excess intake: -- due to parenteral nutrition Decreased loss: -- very common cause is renal failure (pt can experience oliguria <400 mL or anuria <30-50 mL or 0 in 24 hrs.) -- Or using potassium sparing diuretics like spironolactone or ACE inhibitors -- Adrenal insufficiency - can't excrete potassium Shift of potassium -- Associated with Metabolic acidosis: High concentration of hydrogen ions. -- To compensate the H+ ions move intracellularly which causes the (prev. intracellularly) K+ to shift out of the cell causing hyperkalemia ---- Ex. a pt in DKA. Key finding is weakness. -- Muscle most commonly affected is the heart. -- Also causes prolonged PR interval. -- It is life threatening causing vtach and vfib (The # 1 cause of death associated with hyperkalemia is cardiac) -- Can lead to a heart block or ventricular fibrillation.

True or False The majority of surgeries are done in hospitals. Physical Setting of Surgeries Important question prior to surgery:

FALSE 70 - 80 % of surgeries are done in outpatient settings. • Inpatient • Ambulatory Setting Who is driving you home?

Spinal and Epidural Anesthesia - position

Fetus position - used, also used for an LP.

Management of Fluid Volume Deficit - fluid replacement (oral v parenteral; crystalloids v. colloids) - safety precautions (risk for _____; risk for ____) - treatment of underlying cause (two sensitive indicators of successful fluid resuscitation) - special precautions for HF and renal pts/ what to monitor

Fluid Replacement - Oral versus Parental / Crystalloids vs Colloids: We may also have to infuse albumin to increase the oncotic pressure to keep the fluid intravascularly. (Ex. Pt with liver involvement or massive blood loss.) o Teach UAP to offer 2-4 oz. of fluid every hour to pt. If incontinence is a concern, ensure the UAP understands that withholding fluids is not appropriate to prevent the dehydration. • Safety Precautions: low BP and orthostatic hypotension can increase risk for falls. The older adult may also have AMS/confusion placing them at high risk for falls; Risk for over-hydration Treatment of underlying cause: Fluid replacement! Start with NS. o Two sensitive indicators of successful fluid resuscitation: ---- 1. HR normalizes, it decreases in rate and improves in quality. ---- 2. Increase in urine output. BP would then increase and RR normalizes. Also evaluate the pt for fluid overload. Especially if they have heart and renal involvement, which would place them at a higher risk for fluid overload. Assess for crackles, and SOB. o The two most important areas to monitor during rehydration are pulse rate and quality and urine output.

The Fulmer SPICES Framework - "marker" conditions can lead to what (3 outcomes) - purpose of tool

Fulmer is a nurse who developed this tool. These "marker" conditions" can lead to longer hospital stays, higher medical costs and even deaths. • Sleep disorders • Problems with eating and feeding • Incontinence • Confusion • Evidence of Falls • Skin Breakdown Purpose of Tool: a quick assessment tool! if a person identifies problem in an area, do further assessment and tell health care provider, because it might require further interventions

"I" in SPICES - common in what type of setting - causes - assessment

Incontinence - these problems are not physiologic changes of aging, but are very common in both the hospital and long-term care setting o Causes: increased with aging, medications, functional loss, skin breakdown o Assessment: I/O

Phlebitis - type of fluid - s+s - actions to take

Inflammation of the vein. Appears redness and swelling, warm to touch. Stop infusion Remove the cath Restart IV elsewhere Document using the phlebitis scale.

Fluid Compartments (%) - intracellular - extracellular --interstitial --intravascular --trans cellular

Intracellular 66% of TBW Extracellular 34% of TBW Interstitial Intravascular Trans cellular 75% 25% 1%

Treatment for Hypomagnesemia - IV tx used (how should you use it) - assess ______ hourly - hypomagnesemia causes ____ toxicity - discontinue drugs that promote magnesium loss (2 types of diuretics, 1 antibiotic, drugs containing ____)

Magnesium replacement: • Intravenous Magnesium Sulfate - give VERY SLOWLY. Given as a continuous infusion. Low mag increases excitability of the muscle, so high levels will decrease excitability. Assess DTR's at least hourly in the pt receiving IV mag to prevent hypermagnesium. Treat Cause **Hypomagnesemia causes dig toxicity Drugs that promote mag loss, such as high-ceiling (loop) diuretics, osmotic diuretics, aminoglycoside antibiotics, and drugs containing phosphorus, are discontinued.

Medications that affect anesthesia and surgery response include: (what is the main concern) - anticoagulants (exception via what route of admin) - NSAIDs - steroids - antihypertensives * - diuretics - insulin/oral diabetics - analgesic - MAO inhibitors

Main concern for a surgical pt is bleeding - Anticoagulants - warfarin, heparin (exception: given IV it has a shorter half-life so it's stopped a few hours before surgery) - Nonsteroidal antiinflammatory drugs - ASA, Naprosyn, Ibuprofen - Steroids - such as prednisone, will suppress the immune response. In relation to surgery it can increase the risk of infection and poor wound healing - Antihypertensives - should still take it with a sip of water the morning of surgery. Check hospital policy and procedure. In others, clarify with the doctor. - Diuretics - Insulin, oral diabetics - Rx: NPH (intermediate) insulin the morning of surgery. Check the BG first. Remember BG increases in surgery. Call the doctor. Based on their current lab value, they might reduce the dose of insulin, but you do not automatically hold it just because the pt is NPO. - Analgesics - for pain - Monoamine oxidase (MAO) inhibitors - Should be weaned off the pt for several weeks

Infusion Therapy: Vascular Access Device - most common organisms associated with catheter related blood stream infection - who's at risk? - ways cath related blood stream infection occur (2 common, 2 lesser common) - CDC recommendation

Most common organisms associated with a catheter related blood stream infection are staph, pseudomonas and fungal infections (immunocompromised individuals most at risk). Causes: • Cath itself becomes infected - due to inappropriate technique during insertion, which we can control • Contamination of the skin - which can contaminate the cath, such as a dressing change • 2 lesser common: 1 - fluid itself becomes contaminated. When bag was hung, ex. Punctured accidentally. 2 - pt has an infection somewhere in the body and it translocated to the cath site. CDC recommends that only trained individuals start IV's, usually called an infusion team, which start IV's in the hospital.

Pt Reports "pins and needles" running down their arm - caused by: - actions to take - avoid veins on the ______

Most likely nurse hit a nerve. Remove, start over. If pt reports tingling, feeling "pins and needles" in the extremity, or numbness during the venipuncture, it can indicate nerve puncture. If any of these symptoms occur - stop the IV insertion - remove the cath and choose a new site. Avoid veins on the palmar side of the wrist because the median nerve is located close to veins in this area, making venipuncture more painful and difficult to stabilize.

Physiologic responses to surgery and anesthesia include - neuro endocrine - thermo regulatory

Neuroendocrine: stress response Thermoregulatory: o Unplanned hypothermia: OR temperature causes a decrease in body temperature, causing shivering and heat loss. • In the OR you want to maintain a cold environment and humidity. • To increase body temp. : bear hugger or warm fluids o Malignant Hyperthermia: genetic defect, hyperthermia, muscle rigidity, resp. and metabolic acidosis • Most commonly occurs during surgery • General anesthesia, in particular inhaled gases • Can occur 72 hours (3 days) post op • Early s/s: tachycardia, acidosis (caused by hypercarbia (increased CO2), and decreased oxygenation). Anaerobic metabolism will predominate - so give bicarb, electrolyte imbalances, increased potassium and increased calcium. • Later s/s: temp increase (hyperthermia), can go as high as 111 deg F, muscle rigidity o Treatment: remove cause, hyperventilate, cool • Stop the gas, remove the cause • Airway will be the #1 concern o Give Dantrolene - muscle relaxant o Maintain airway, provide high flow oxygen o For acidotic state: give bicarb and hyperventilate the pt for increased CO2 so if they're intubate them, bag them o Fluids and cooling measures o Push regular IV insulin to decrease the potassium and move it back into the cell. Give D50 with the insulin so that blood glucose does not drop.

Infiltration - type of fluid - s+s - actions to take

Non-vesicant fluid /medication is now leaking into the surrounding tissue. See swelling and edema. Pt says it hurts. Stop the infusion, remove it and change the site. If there is edema in the hand, elevate it and put a cool compress on it to relieve discomfort and reduce swelling. Complete incident report.

Magnesium - normal range - function -- ___ most abundant IC cation -- involvement with the heart -- influence over which pump -- bound to which protein -- primarily excreted by the ____

Normal Range: 1.3-2.2mEq/dl Functions: • Second most abundant Intracellular cation • Contracts the myocardium • Influences transport of Na/K across cells • Bound to albumin • Primarily excreted by the kidneys

Calcium - normal range - functions -- found in what fluid compartment -- regulated by what hormone/vitamin -- opposed by ____ -- bodily function (NS, cardiac, formation of _____) -- majority found in ______ -- most of calcium in _____ (to what protein) -- name for "free and available calcium" -- ca is needed for forming a _____

Normal Range: 9.0-10.2mg/dL Ionized Calcium Functions • Cation found in ICF, regulated by PTH, vitamin D (required for Ca absorption) and opposed by calcitonin • Transmission of nerve impulses • Contraction of cardiac muscle • Formation of bones & teeth: -- Most of calcium is found in the bones and teeth -- Most of it is bound. Also some is bound to albumin. --Only a small percentage of calcium is called ionized calcium, meaning it's free and available. In clinical: given 2 Ca levels. In sick pt's, we look at both. Coagulation process: calcium is needed for clot formation.

Surgical Scrub, Gowning, and Gloving

Once they're scrubbed in, they help the person gown and put on gloves. A and B - the person is already wearing a head cover, mask and boots. Then he scrubs. C - nurse helps person gown. E - person puts on gowns. If circulating nurse is passing something through the sterile field, she only opens the layer and the scrubbed personnel grabs it.

Intracellular and Extracellular Transport of Body Fluids (Water)

Osmolality (concentration of solutes in water) exerts osmotic pressure (ability of solution to attract water), causing osmosis (movement of water across cell membrane from area of low-solute to high-solute concentration).

Movement of Fluid: Extra cellular & Intracellular Compartments - PASSIVE TRANSPORT - osmosis (definition) -- used in what type of Tx? -- what influences the mvmt of water -- osmolality definition -- osmolality normal range* -- osmolality significance -- osmolality regulated by release of ____ -- example of drug that is an osmotic diuretic/ example of when to use the drug

Osmosis- Water moves across a semi-permeable membrane from an area of low solute towards a region of higher solute concentration o Used in dialysis! o The concentration of solutes influences the movement of water Osmolality/Osmolarity: measurement of number of particles in a solution or the concentration of a solution o Norms: 275-300 mOsm/kg o Significance: "High and dry", the higher the solute concentration the less fluid your pt has o Regulated by ADH release o Mannitol is an osmotic diuretic that helps pull out fluid for a pt with TBI who has cerebral edema. So you have to monitor the serum osmo!

Intracellular and Extracellular Transport of Solutes: - Passive Transport -- diffusion (example/ alveoli/ dialysis) - Active Transport -- Na/K pump

Passive Transport • Diffusion- Solutes move across a semi-permeable membrane from an area of higher concentration towards a region of lower particle concentration o Alveoli concentration of CO2 and O2 o In dialysis we are trying to pull off electrolytes, because the kidneys are not excreting them Active Transport • Sodium-potassium pump: Energy is required for process, since molecules are being moved against a concentration gradient- ATP

Surgical Attire - showing up to surgery - hat - scrubs - shoe covers - masks - face shields/eyewear - lead aprons and thyroid shields -- time out

People who work in the OR come in with street clothes and a lab coat. • Hat: Put on first; prevents contamination of scrubs • Scrubs: Closely woven, shirt tied or tucked • Shoe covers: Worn if splashes or spills anticipated • Masks: Prevent contamination by droplets • Face shields and eyewear: Protect from splashing and spraying • Lead aprons and thyroid shields: Protect from exposure to radiation Taking a "time out" means you take a pause and again, identify the pt, body part, and procedure. If there is any inconsistency you stop and collect necessary information.

Treatment for Hypokalemia - potassium replacement -- IV- solutions used; special precaution -- nurse intervention -- special measures (2) -- K+ is a severe ____ irritant/never given ______ - po - enteral - ECG: indications of effective therapy

Potassium replacement: Intravenous: SAFETY o IV KCl - for severe hypokalemia, it is a HIGH RISK drug, it's a slow continuous infusion. Before infusing any IV soln. containing potassium chloride check and recheck the dilution of the drug in the IV soln. container. o Pt's needs to be on a cardiac monitor o Infuse over a slow rate o Potassium is a severe tissue irritant and is never given by IM or sugQ injection. ***Potassium is not given by IV push to avoid causing cardiac arrest*** • PO: if mild, give potassium supplements • Enteral Treat Cause HYPOkalemia EKG changes: Prominent U wave Indications of Effective Therapy: - ST segment returns to the isoelectric line - T waves increase in size and are positive - U waves decrease or disappear

Potassium - normal range - function (main cation in ____; transmission of ____; contraction on what type of muscle?)

Potassium: Normal Range: 3.5-5.0mEq/L Functions • Main cation in ICF • Transmission of Nerve fibers • Contraction of skeletal, smooth & cardiac muscle A slight decrease or increase is significant when it comes to potassium.

Preoperative Preparation - pre-op checklist (site marking/ID) - pre-op meds -- 3 type of benzodiazepines (important note about consent) -- 3 types of anticholinergics (risk for ____ post op) -- 2 types GI -- antibiotics (ideal time to admin to pt) - nurses responsibility

Preoperative Checklist: Site Marking, Identification (Name, DOB, MRN) - X is no longer used - Site should be marked with initials and a permanent marker - Important to re-identify the pt and the correct surgery Preoperative Medications - Benzo's: Make sure consent and questions are clarified PRIOR to administration --Midazolam (Versed) Diazapam (Valium), Lorazepam (Ativan) Anticholinergics to reduce secretions; Post op they might be at higher risk for urinary retention --- Glycopyrrolate (Robinul) Hyoscine Hydrobomide (Scopalamine) GI prophylaxis --- such as a PPI or histamine antagonists. Antibiotics --- ideal time for a pt to get an abx is within 1 hour of surgery. It is the nurse's responsibility to get the pre-op checklist completed. Others can contribute.

Deficient Knowledge Interventions: The Role of the Nurse - role of doctor/nurse - consent reflects (2 qualities) - scope of practice

Preoperative teaching Informed consent: -- Surgeon is responsible for obtaining signed consent before sedation and/or surgery. -- The nurse's role is to clarify facts presented by the physician and dispel myths that the patient or family may have about surgery. A consent reflects autonomy and self determination Clarify information within the nursing scope of practice. If the pt consented and they ask, will I get an IV? Yes you can answer and reinforce. But if they ask what is the complication rate? No. Nurse should witness the pt signing the consent, not obtain the consent.

"P" in SPICES - preferred to be _________ than _________ - causes - assessment

Problems with Eating and feeding - 20% of older adults hospitalized experience nutritional problems, it is better/preferred to be overweight than malnourished o Causes: altered taste buds, absent dentures, GI problems, functional ability (ex. Post CVA), dysphagia o Assessment: observation, maintain calorie count

RENIN- ANGIOTENSIN-ALDOSTERONE CASCADE (RAAS)

Receptors sense a decrease in blood volume. * Renin is released from the JGA. * Renin converts Angiotensinogen to angiotensin 1. * Angiotensin 1 is converted to angiotensin 2, through ACE. * Angiotensin 2 stimulates the release of aldosterone from the adrenal cortex. ****BP is increased. ****Na and water is reabsorbed or retained. ****Potassium (K+) is excreted.

Extravasation - type of fluid - s+s - actions to take

Site has edema. Pt c/o pain. However, it is a vesicant fluid or medication. (Ex. Chemo drugs: anthracycline and alkylating agents) Also phenytoin (Dilantin) - anticonvulsant. Vesicants are typically very irritating. First thing you do is stop the infusion. Get a syringe and using appropriate technique, remove the tubing and connect the syringe to the hub of the IV cath and aspirate to remove any vesicant fluid that is still in the cath. You leave the cath in place if there is a rx for antidote Give antidote, then remove the IV.

Peripheral IV Device - sizes (18-22; what they're used for) - steps in insertion

Sizes: 18- 22 gauge - 18 has a larger lumen - used for blood, large amounts of fluids over a rapid/brief period of time. - 20G is the go to, adequate for all therapies - can be used for blood transfusion. - 22G is smaller, used in older adults. Veins are fragile. Tourniquet is used to obstruct venous blood flow, placed 2-6 inches above the site. Make a fist. Tapping is not recommended because it can break a vein. Use clean gloves. You cannot touch the area after you apply the chlorhexidine. Before you procede the site should dry. Level the needle when you see flashback of blood. Then advance the catheter and press on the device to retract the needle. Secure with a transparent dressing, no gauze. Date, time and size of G. If you cannot feel the vein, use sterile gloves.

"S" in SPICES - causes - assessment (which assessment tool will we use; which type of injury is common among chronic steroid therapy use)

Skin Breakdown o Causes: pressure ulcers, friction, shearing forces o Assessment: Do you have an IV? Use the BRADEN SCALE for predicting pressure ulcer sore risk. Skin tears are also common in older adults, especially the old-old group and those who are on chronic steroid therapy.

"S" in SPICES - causes (external/internal) - assessment (questions to ask/intervention)

Sleep Disruption o Causes: due to external stimuli: lights, noises OR internal: pain o Assessment: How did you sleep last night? Do you feel rested? If it's interrupted...How long before you fell back asleep? Interventions: sleep hygiene, avoid caffeine products, medications (increased risk of falls)

Hyponatremia - etiology (excessive water intake; sodium loss) - s/s -- neuro (cause of behavioral changes, cause of cognitive changes; consequence low of extremely low sodium levels -- muscle (two most important muscles, which area of the body is sensibly affected, high Na slows the mvmt of ___ into the cardiac cells)

Sodium Imbalance: HYPOnatremia <135 Etiology: •Excessive water intake: relative hyponatremia • SIADH • Water intake, no Na •Sodium loss: • Diuretics • GI loss • Diaphoresis Clinical presentation s/s fluid overload: • Neuro impairment - cerebral changes are the most obvious problems. Behavioral changes result from cerebral edema and increased intracranial pressure. A sudden onset of acute confusion or increased confusion is often seen in older adults who have low serum sodium levels. When sodium levels become very low, seizures, coma, and death may occur. o Change in LOC o Seizures • Muscle weakness: Consider heart and diaphragm. Deep tendon reflexes diminish and muscle weakness is worse in the legs and arms. If muscle weakness is present, immediately check respiratory effectiveness because ventilation depends on adequate strength or respiratory muscles. With hypernatremia, high sodium levels slow the movement of calcium into the heart cells, decreasing cardiac contractility.

Hypernatremia - etiology -- relative (mainly due to ___; other causative agents; clinical presentation-NS affected how) -- absolute (excessive ____; diseases associated (2); use of drugs associated; over-secretion of ____)

Sodium Imbalances: HYPERnatremia >145 Etiology: •Relative hypernatremia: -- Water loss is greater than Na loss (relative hypernatremia is mainly due to fluid loss): • Diabetes insipidus: not enough ADH • Osmotic diuresis: ex. Mannitol • Decreased fluid intake •Absolute hypernatremia: -- Excessive Na intake: • Excessive administration of IV solutions • Excessive oral sodium ingestion • Cushing's syndrome/disease • Corticosteroids • Kidney failure • Hyperaldosteronism Relative hypernatremia Clinical presentation: • Dehydration: thirst, dry mucous membranes, decreased LOC, seizures o Neuromuscular system is the most affected by any sodium changes. Might start with some cognitive changes and progresses to potential seizure activity.

The ANA Standards of Clinical Practice - (2) - standards of _____________

Standards of Care: Address nursing process and competency in nursing care Standards of Professional Performance: Address expected quality of care, ethics, collaboration, and other responsibilities

Positioning during surgery

Supine - use pads to minimize pressure. Increased risk of pressure ulcer development in the OR: weight, age, nutritional pre-op stage, length of surgery Prone - concern is airway lateral position - trochanter pressure is a concern. Lateral kidney - concern is nerve injury at the brachial plexus. lithotomy position - concern is nerve damage, especially peroneal nerve which leads to foot drop. Another concern is a drop in blood pressure with fast repositioning of the legs into a flat position.

Biopsychosocial Responses to Surgery - what system of the NS takes over - neuroendocrine (cardiovascular, respiratory, GI, Hormonal) - psychogenic - sociologic (ORIF

Sympathetic system dominates. - Neuroendocrine: Includes cardiovascular, GI, pulmonary, hormonal changes --Cardiovascular: increased HR -- GI: paralytic ileus -- Hormonal: increased cortisol, increased blood glucose. DM pt will have an increased need for insulin. - Psychologic: Includes anxiety; fear -- Low levels of anxiety are beneficial - Sociologic: Includes role adaptation, potential financial, lifestyle, supportive care stressors -- ORIF - open reduction and internal fixation of the hip surgery; as a result ADL's will be decreased, if they use crutches they're going to need home adjustments if they have (ex. a 2 story building. A social worker will be an invaluable resource.)

The Academy of Medical-Surgical Nurses (AMSN)

The backbone of modern nursing and the practice foundation of virtually all health care.

Intraoperative Phase - begins/ends - what occurs in the OR

The intraoperative phase begins with transfer of the patient onto the OR bed and continues until the patient is admitted to the PACU. In the OR: pt is identified again, check surgical mark site, check consent

Tonicity - definition - isotonic (definition/example/risk for ___) - hypertonic (definition/example/cell will___) - hypotonic (definition/example/cell will ___/C.I. in pt with___)

The measurement of the osmotic pressure of a solution (osmolality) Isotonic - a solution with the same osmolality of serum and other body fluids (0.9% NS) o Worry about fluid overload when giving a pt NS HYPERtonic - a solution with an osmolality higher than that of serum, causes ICF compartment to shrink (D5 ½ NS and 0.45 NS) o fluid is drawn from the cell to the intravascular space = shrinks the cell o Ex. Will help with TBI HYPOtonic - a solution with an osmolality lower than that of serum, causes ICF compartment to swell (D5W) o fluid will move from the intravascular space into the cell = cell swells o Ex. Contraindicated in a pt with a TBI, and cerebral edema, because it will cause more swelling

Patient Items Removed for Surgery

They should be removed and sent home with a family member, so that they're not lost. You usually document. If there is no family, remove them. Do not leave them next to the bed. At Jackson, bring them to a cashier, to put in a locker. If items are lost, the hospital has to buy the dentures. Hearing aid, should be left in place and notify the OR nurse that the pt has them. They are removed when the pt is on the table. Nail polish should be removed because it interferes with O2 sat and it interferes with cap refill.

"Push and Pull" Factors of edema (increased/decreased) Example

Think of hydrostatic pressure as push and colloid osmotic pressure as pull Edema: Does not necessarily mean fluid overloaded, but fluid is displaced! Decreased oncotic pressure Increased hydrostatic pressure ex. SIRS

Total Body Fluid - __% of total body weight - __% total water body weight - newborn body fluid - varies according to (4 factors)

Total Body Fluid--Is approximately 60% of total body weight o Percentage of total body weight that IS water is different! o Water accounts for 45% to 75% of body weight. Newborns have a higher percentage of body fluid. In the newborn infant more than half of total body fluid is extracellular. As the child grows, proportions gradually approximate adult levels. • Varies according to: a. Muscle Mass - has a higher percentage of fluid. Men have higher body mass than females. b. Electrolytes c. Body Fat - has a decreased percentage of fluid. d. Age

Peripheral IV Access- Nursing Management - questions to ask - assess site - replacement of IV from __ to __ hours - complication

Trace anything coming out of your pt, what date is on the site? what is the solution? Is it infusing at the appropriate rate? Is it dated? Is it labeled? • Assess IV site: redness, swelling, tenderness, blood return, secure site • Calculation of administration • Good hand hygiene • Replacement 72-96 hours • Replace tubing 72-96 hours • Complications: Infiltration, extravasation, phlebitis, infection

Treatment for Hypocalcemia - calcium replacement (IV med/type of med) - vitamin replacement - oral for _____ condition - when its a result of hyperphosphatemia give ____

Treatment for Hypocalcemia Calcium replacement: • Intravenous- 10% calcium gluconate or chloride slowly for emergencies: HIGH RISK, continuous and slow infusion • Vitamin D replacement: necessary for Ca absorption • Oral calcium for chronic hypocalcemia: can cause constipation • When hypocalcemia is a result of hyperphosphatemia - we can also give aluminum hydroxide which is a phosphate binder, will lower phosphate and cause a reciprocal rise in calcium level Treat Cause

Treatment for Hyponatremia - excessive water intake - sodium deficit (severe cases IV tx)

Treatment for Hyponatremia Excessive water intake: •Fluid restrictions - Increasing oral sodium intake and restricting oral fluid intake •Diuretics - only used if hyponatremia relative to fluid overload, because diuretics will cause more sodium, than what is already lost, to be lost with water. Sodium Deficit: •Replace sodium - IV, PO, Enteral feedings. When hyponatremia occurs with a fluid deficit, IV saline infusions are prescribed to restore both sodium and fluid volume. Severe hyponatremia may be treated with small infusions of hypertonic saline, most often 3% or 5% saline.

Central Venous Catheter: Tunneled - type of catheter/ names (3) - tunneled through which area of skin - length of time - how is it inserted - where is it inserted - purpose of catheter entry separation

Tunneled through the subcutaneous tissue. Long term use - Cuffed catheters inserted surgically, threaded under the skin - tip into SVC. - A portion of the cath is lying in a subcutaneous tunnel, separating the points where the catheter enters the vein from where it exits the skin. - This separation is intended to prevent the organisms on the skin from reaching the bloodstream. Decrease infection - The cath has a cuff made of a rough material that is positioned inside the subcutaneous tunnel. The cuff becomes a mechanical barrier to germs. These cuffs commonly contain antibiotics, which reduce the risk for infection. Causes granulation. Also known as a hickman, broviac and leonard cath. Tunneled and implanted port are inserted in the OR not by the beside.

Treatment for Hypernatremia - for water loss greater than sodium loss -- start with ____; or give __tonic fluid replacement in pts that have ______ - for excessive Na intake - assess:

Water Loss > Sodium loss: • Free water boluses (IV/oral) • Hypotonic fluid replacement: fluid replacement usually starts mainly with isotonic fluid. Sometimes hypotonic solutions is used first if the pt usually has intracellular dehydration. • Treat cause Excessive Na intake: • Diuretics: loop or thiazides, but only used in pt who has absolute hypernatremia, not in a pt with relative hypernatremia. Because remember diuretics, will get rid of Na but also water/fluids. • Treat cause Assess lab values & patient for possible complications

Local Anesthesia - example - delivered ______ by local ______ - pt remains ______

ex. CVC insertion with lidocaine • Briefly disrupts sensory nerve impulse transmission from a specific body area or region • Delivered topically and by local infiltration • Patient remains conscious and able to follow instructions - airway is intact, will not cause airway problems. Will not immobilize the pt. Person can still feel anxious.

Wound Closure

minimally invasive surgery - closed with glue and steri-strips you do not change the first post op dressing, the surgeon does. Once it is removed and you've changing it as prescribed, note about the suture line: redness, discharge, drainage, is it well approximated (two edges are touching)? Notify the MD with abnormal findings. Montgomery strap - used for a large abdominal incision that requires dressings 3x per day, used to prevent skin breakdown. It consists of two sides, that are untied and the dressing is underneath. The dressing has no tape, minimizes skin breakdown.

Management of Fluid Volume Excess - Patient Assessment- I/O - edema/secondary complication - respiratory - cardiac - weight

o Edema - is it pitting or non-pitting? -- Secondary complication is skin breakdown, increasing risk for developing a pressure ulcer o Crackles, SOB, tachypnea, decreased oxygen saturation (SpO2) o Pulmonary edema, pink frothy sputum o Bounding pulse (within normal parameters), hypertension, JVD o Weight gain - fluid retention may not be visible. Rapid weight gain is the best indicator of fluid retention and overload.

Nursing Assessment of Fluid Volume Excess - pulse rate - lab values (Na, BUN, HcT, HgB, protein) - prevent _______ - pharmacological therapy - fluid restriction - treat underlying cause (when would K+ affect fluid volume)

pulse 0 to 4 +: 0 indicating no palpable pulse; 1 + indicating a faint, but detectable pulse; 2 + suggesting a slightly more diminished pulse than normal; 3 + is a normal pulse; and 4 + indicating a bounding pulse. Lab Values: Hyponatremia- 134-145 Low BUN- less than 10 Low HcT: (men) 38.8-50%; (women) 39.9-44.5% Low HgB: (men) 135-175 g/L; (women) 120-155g/L Low serum protein: 6 to 8 g/dl (albumin: 3.5-5.0) •Prevent skin breakdown •Pharmacological therapy - Diuretics if kidney failure is not the cause -- Use if pt has normal urine output. Diuretic of choice is furosemide (Lasix), which excretes fluids and potassium. •Fluid restriction - restrictions of both fluid and Na restriction. For more severe fluid overload, the patient may be restricted to 2-4 g/day. -- Includes any medications or IVs! -- Ex. order: 1200 mL's for 24 hrs. - alert the pt, dietician, UAP o Potassium is usually not affected by fluid volume, unless they have renal etiology. •Treat underlying cause: If the cause was renal failure tx with dialysis

Drains

used to promote draining. Hemovac vs. Jackson Prack (JP). Monitor output, amount, color and consistency, which will vary on the stages of healing. Press it in before shutting the lids to create a vacumm. Penrose drain - sits inside the dressing, draining from the wound into the gauze. T-2 also draining into a dressing.

Fluid Replacement Therapy: Crystalloids Hypotonic Solutions - 4 solutions - concentration distribution (in relationship to plasma) - what happens to the intracellular space - indications - complications - contraindications

• 0.45% saline, 2.5% dextrose, 33% saline, D5%W* Less concentration outside of the cell than inside of the cell. Lower concentration than plasma • Decreases intravascular osmolality • Results in intracellular expansion/hydration • Used for cellular dehydration • Complications: Shock, increased ICP • Contraindications: anasarca, cerebral edema, hypotension

Skin Preparations - hibiclens

• A break in the skin increases risk for infection. • Patient may be asked to shower using antiseptic solution. Hibiclens prior to surgery and the morning of surgery

Practice Settings

• Acute Care • Skilled nursing facilities - Lennar's focus for ex. is on ambulatory • Rehabilitation - Inpatient/outpatient • Outpatient settings- Clinic, Primary Care, Surgical, Oncology care • Hospice • Community Health Settings • Occupational Health • Student Health

Complications of Local or Regional Anesthesia

• Anaphylaxis • Incorrect delivery technique • Systemic absorption • Local complications Hypotension and headache is seen with epidural and spinal block, because it blocks the sympathetic system

Pre-Operative Assessment: Nursing Diagnoses

• Anxiety • Risk for Ineffective Airway Clearance • Risk for Ineffective Peripheral Tissue Perfusion • Knowledge Deficit

Advancing Care Excellence for Seniors- ACES units (acute care of the elderly) - Essential Nursing Actions

• Assess Function and Expectations • Coordinate and Manage Care • (Use) Evolving Knowledge • (Make) Situational Decisions

Respiratory System Assessment

• Assess for a patent airway and adequate gas exchange • Note artificial airway, when applicable • Rate, pattern, and depth of breathing • Breath sounds • Accessory muscle use - intercostal and trapezius • Snoring and stridor • Respiratory depression or hypoxemia

Nursing Process - ADPIE - ex. test question

• Assessment • Diagnosis • Plan • Intervention • Evaluation For exams! The question stem could have for ex. "walk into pt room, they appear to be sleeping with a RR of 10. What would you need to do?" Do you have enough info to intervene? NO, you need to further assess

CVC Sites: Catheter Complications

• Bleeding/drainage from the site • Difficulty advancing the catheter • Catheter malposition • Catheter migration • Nerve damage • Catheter sepsis - cath related blood stream infections. Know how to prevent/minimize and what to assess for. • Phlebitis/Cellulitis - phlebitis is local. Cellulitis means the infection has progressed in the tissue. • Cardiac associated problems • Catheter or air emboli • Arterial damage

Intestinal Preparation - why do pts receive bowel/intestinal preparations - evaluate the effectiveness of a bowel prep by _____

• Bowel or intestinal preparations performed to prevent injury to the colon and to reduce the number of intestinal bacteria. • Enema or laxative may be ordered by the physician. • How does the nurse evaluate the effectiveness of a bowel prep? Make sure you ask: When was the last enema? When was the last bowel movement? What did it look like? It should look like water if they are ready for surgery; greenish/brownish tinge. No solids.

Pre-Operative Diagnostics - CBC - BMP - coagulation studies - HCG - chest studies (cardiac, lungs, PFT) - urine - type and screen /type and cross (what is the coumbs test)

• CBC - WBC, assess for infection, also hct, hbg • Basic Metabolic Panel - electrolytes, BUN, creatinine • Coagulation studies - PT, INR, PTT and platelets • HCG - human chorionic gonadotropin, pregnancy test on any woman who is of child bearing age • 12 Lead EKG • Chest X-ray - common in middle age to older adult • PFT's - pulmonary function test, for a COPD or asthmatic pt. • U/A - urine analysis • Type and Screen or Type and Cross Match - cross match is more specific. Coumbs test, they take the pt and donor blood and mix it, looking for antigen-antibody compatibility. Certain types of surgeries are known to cause a lot of blood loss so they order for ex. 2 units type and cross prior to surgery.

Pre-Operative Assessment - Cardiac - Pulmonary (amt of time before surgery smoking should stop; can inc. the risk for ____; risk of atelectasis with what disease; infection and surgery

• Cardiac • Pulmonary - smoking. Smoking 4-5 weeks prior to surgery should be decreased. Smoking can increase the risk for poor wound healing. COPD is a comorbidity that can increase anesthesia, risk of atelectasis and pneumonia. We do not want to take someone to surgery who is infected. Exception: I & D (incision and drainage) for necrotic foot.

Physiological changes with age - cardiac - respiratory - GU - skin - pain

• Cardiac: hypertension, decreased CO, decreased peripheral vascular perfusion • Respiratory: loss of elasticity and recoil, decreased vital capacity (forceful exhale following a deep maximal inhalation). So for a post op pt, it will take them longer to get rid of anesthesia. Also if you intubate them it will be more difficult to extubate them. • GU: incontinence is more prevalent (incontinence is not normal), decreased GFR, nocturia increases -increasing the risk for falls. • Skin: loses elasticity - so assessing hydration status via skin turgor is not ideal, lower core body temp - so we would expect a fever at 99 and not >100 because it is closer to their body temp. • Are more likely to underreport pain b/c they think pain is part of aging and they might be in denial of their illness

Electrolytes - cations (definition/examples) - anions (definition/examples) - measured in ___ - serum levels indicate _________ concentration

• Cations: Positively charged ions (Sodium, potassium, calcium, magnesium) • Anions: Negatively charged ions (Chloride, phosphate and bicarb) • Measured in milliequivalents (mEq) • Serum levels indicate extracellular concentration - Remember we are measuring the extracellular concentrations, not intracellular! How do we measure them? perform CMP and monitor them in urine

Immediate Neurological System Complications

• Cerebral functioning • Muscular irritability, restlessness and delirium, pain recognition, Reason • Older adult is at increased risk for delirium. Underlying reasons why they're at higher risk is due to a change in environment, internal/external stimulus, dehydration, meds used ex: Ranitidine (GI med) can increase risk of delirium. • Motor and sensory assessment important after epidural or spinal anesthesia: • Sense of touch, pain, warmth, cold, movement • CMS (circulation, motor, sensory) checks

Urinary Retention post op

• Characterized by inability to void over a 6- to 8-hour period after surgery. Assess I & O. Feel for bladder distention. If ambulatory take them to the bathroom. Then catheterize them. • Can occur after spinal anesthesia; surgery of the rectum, colon, gynecologic structures • Usually resolves within 48 hours • Urinary tract infection • At risk due to anesthesia and anticholinergics (given to drive up respiratory secretions)

Evidence-based practice - clinical expertise - individual patient _______ and _________ - best practices - example

• Clinical expertise - improves pt outcomes and does not cause harm • Individual patient rights and situations • Best practices (as determined by research and the evaluation of said research) • Anecdotal findings is specific to 1 pt (ex. Livestrong bracelets "decrease pain")

Movement Between Vascular and Interstitial Spaces - colloid oncotic pressure -- definition -- relationship to fluids in the interstitial space -- frequently monitored colloid -- proteins keep fluid ________ -- what happens when you don't have oncotic pressure -- conditions of low albumin

• Colloid Oncotic Pressure: pulling pressure exerted by proteins/colloids in the blood • Pulls or absorbs fluid from the interstitial space • Colloids can also influence the movement of fluid • Colloid frequently monitored: albumin • Proteins maintain colloid oncotic pressure, keeping the fluid intravascularly • If fluid leaks out and they don't have oncotic pressure = edema • Low albumin conditions: Liver failure pt's, malnourished pt's (ex. older adult, alcoholic, anorexic)

Fluid Replacement Therapy - colloids

• Colloids - given to increase oncotic pressure and keep fluid intravascularly • Blood & Blood Products • Increases colloid oncotic pressure • Restores circulating volume • Pulls interstitial water into intravascular space

Surgical Procedures - ectomy - rrhaphy - ostomy - otomy - plasty - scopy

• Craniotomy - Put birr holes into the scalp • Craniectomy - Pt with epidural hematoma. Craniotomy first, then they remove that piece of skull to alleviate pressure and put it in the peritoneal cavity. • Cranioplasty - then they take that piece of skull out and replace it. Plastics procedure. • Colostomy • Laparoscopy

Fluid Replacement Therapy: Crystalloids Hypertonic Solutions - 3 common solutions - concentration distribution in relation to plasma - what happens to the intracellular space

• D5% 1/2NS (5% dextrose in 0.45%NS), D5%NS, D5%RL More concentration outside of the cell than inside of the cell. Higher concentration than plasma • Increases intravascular osmolality • Results in intracellular & interstitial dehydration

Purpose of Surgery - diagnostic - curative - reconstructive - ablative -cosmetic

• Diagnostic: Aids in diagnosis (e.g., breast biopsy) • Curative: Resolves condition by removing diseased tissue. Ex. Appendectomy. • Reconstructive: Corrects deformity, repair injury, or improve functional status • Ablative: Excises tissue that is worsening existing condition. Ex. Certain types of dysrhythmias. • Cosmetic: Improves appearance.

CVC Sites: Documentation - what to document - what to document to make sure the catheter did not migrate

• Document complete assessment • Sterile technique • Prep solutions • Type of dressing • Change of add-on device • External length of the catheter - make sure it doesn't migrate

Acute Pain Negative Effects of Pain Assessment Interventions include:

• Drug therapy - preferred method for delivery post op is IV push or PCA. Used for morphine and hydromorphone (Dilaudid). Basal rate on top of push rate. Ex. 1 mg of morphine every 15 min. They can get another 1 mg every 10 min with a lock out of 10. Main concern is respiratory depression and constipation. IF low RR, wake them, continue to monitor their RR. Have Narcan available. If breathing 2 bpm and they're unresponsive, turn off the pump, stay with the pt while you call RPR. • Complementary and alternative therapies such as: • Positioning • Massage • Relaxation and diversion techniques

Timing of Surgery - elective - urgent - emergent -- what 3 factors vary with timing of surgery

• Elective: Planned, nonessential. Non-life threatening. Have the option to donate blood. • Urgent: Unplanned, requires timely intervention, no immediate threat to life. Ex. Hip fracture, unless they're bleeding profusely. • Emergent: Must be performed immediately to preserve life and limb. Ex. Epidural hematoma. Patient preparation, pt teaching and consent vary with timing of surgery.

CVC Sites: Assessment - purpose - nursing interventions

• Establish a baseline for comparison • How does it look? (color, appearance) • How does it feel? (temperature, pain with palpation) • Is there drainage? (new, old, the same, quality, color, amount) • Is the dressing intact, dry, with no loose borders? • Check catheter position for external migration, kinks or bends - Measure the length of the cath inserted, especially central catheters. We do not want the cath to be pulled out or pulled in. Measure length of what's hanging out at the insertion site. • Does it flush easily? • Is there a blood return? • Assess the track of the vein (observe, palpate) • Infusion pump alarm settings • IV tubing (luer-locked, leaks, clouding, precipitate, blood in tubing) • Observe upper arm and chest wall for signs of edema, collateral vein formation (alternate circulation around vein)

Treatment of Hypermagnesemia - fluid treatment - drug that will stabilize the heart

• Fluids/diuretics • Dialysis - because the number 1 cause is renal failure • Calcium Gluconate - will not necessarily lower the levels, but it will help stabilize the cardiac effects of the high mag. Stabilize the myocardium. • Treat underlying Cause

Factors that Increase the Risk for Aspiration

• GERD • Pregnancy - puts more pressure on the diaphragm • DM - usually have gastroparesis (slowing of GI tract)

Clinical Pathways: Case Management - definition - diagnosis is __________ - factors:

• Guidelines for patient care • Diagnosis—Course of Treatment • Outcome Driven • Maximize quality • Minimize costs of care • Coordination of health care services • Decrease LOS - allows a pt to be treated with a shorter length of stay Ex. Peds Post anesthesia pt How the pt should be progressing over time

Nursing care - community-based care - priorities of care

• Home care management • Health teaching • Health care resources Priorities of Care • Pre Operative - Assessment for baseline and risk. Teaching to provide expectations. Consent is obtained and pt has understanding. Identify. • Intra Operative - identify. Help with positioning. Scrubbing in. Documents, assesses the pt. • Post Operative - ABCD

Movement Between Vascular and Interstitial Spaces - hydrostatic pressure -- definition -- filtration

• Hydrostatic Pressure: created by the weight of fluid pressing against the wall of blood vessels • Forces molecules through the capillary membrane • Filtration- movement of water and solutes from high hydrostatic pressure to low hydrostatic pressure • Hydrostatic pressure is also referred to as filtration • Greater volume --> greater stress on blood vessel --> fluid will leak out --> edema Ex. Pt's with more volume: Hypertension, mostly hypervolemia, also pt with CHF, renal failure, SIADH

Immediate Cardiovascular Complications: Pulses, BP, cap refill, look at the dressing to check for blood loss

• Hypotension - most likely to happen due to blood loss and NPO. Change in 20% or more in baseline BP is a concern. • Hypertension - determine their baseline, did they receive their medication?, are they due for their meds?, can be related to pain if they don't have a hx • Cardiac dysrhythmias The incidence of perioperative myocardial infarction is expected to increase as the population ages and more surgical procedures are performed on older adults.

Distribution of Fluid - intracellular - extracellular (where is the highest % of fluid found in ECF?) - interstitial - intravascular - transcellular

• INTRAcellular- fluid inside the cell o INTRA comprises a higher overall percentage of body fluid of body weight in adults! • EXTRAcellular- fluid outside the cell o Interstitial- fluid between the cells Where is the highest percentage of fluid found extracellularly? Interstitial "third space" ...not intravascular o Intravascular- fluid inside vessels o Transcellular- very small percentage less than 1%, ex.: CSF, synovial, pleural space

Moderate Sedation "conscious sedation" / twilight

• IV delivery of sedative, hypnotic, and opioid drugs to reduce the level of consciousness. • Patient maintains a patent airway and can respond to verbal commands. • Amnesia action is short with rapid return to ADLs. • Etomidate, diazepam, midazolam, fentanyl, alfentanil, propofol (deprivan) and morphine sulfate are the most commonly used drugs. • It is white, lipid based • Short acting - pt has decreased consciousness and amnesia, but as soon as it's stopped LOC returns • Idea is to decrease their consciousness, but maintain their airway. Supplemental oxygen is sometimes given, but they're breathing on their own. • Commonly used for procedures such as: Endoscopy, colonoscopy, sigmoidoscopy

Nursing management of surgery

• Identification Safety • Assessment: upon arrival to OR & intraoperative • Positioning

Hypercalcemia - etiology -- movement -- disease processed associated -- intake of ___ -- bone (occurs in both hypo/hypercalcemia) -- can increase risk of ____ toxicity (cardiac complications) -- what happens to urine? tx?

• Immobilization: decreased weight bearing, causing a loss of calcium from bone • Multiple myeloma: plasma cells proliferate and destroy the bone or any type of bone carcinoma • Intake: by taking a lot of antacids, like "tums" which are high in Ca • urine can become more concentrated in Ca causing renal calculi, so pushing fluids will be part of the treatment*** • Fractures with both hypo and hypercalcemia, bc the source of the Ca loss is from the bone • Hypercalcemia can also increase the risk for dig toxicity and cardiac complications. Hypercalcemia can occur with the use of thiazide diuretics.

Factors influencing the practice of Medical-Surgical Nursing - increasing _________ _________ (immigration) - what population/what conditions - advances in __________ - ____________ care act - monetary ___________ - available ______________________

• Increasing cultural diversity (immigration) • Aging population with accompanying increase in chronic conditions - Highest increase in our country is the aging population • Advances in medical science and technology - extending life, Advocacy for pt wishes is the nurses role in end of life care • Affordable Care Act • Monetary constraints - 20% of population in miami-dade lives in poverty (classified as a family of 4 with income of less than 25k/yr) • Available nursing workforce - there will be a nursing shortage for older adults in the future

Normal aging process - what is it and what may it increase - NICHE - ACES

• Inevitable changes that may increase the elderly clients risk for specific health related problems. • Initiatives specific for elderly care include: o The Nurses Improving Care for Health System Elders or NICHE Project- NYU o ACES Project- NLN

Chronic Illness Characteristics - length of time - leaves ________ on a patient - caused by - requires long period of ________ - periods of _______ and _______

• It is permanent. • It leaves residual disability. • It is caused by nonreversible pathologic alteration. • It requires a long period of supervision, observation, or care. • Remission---Exacerbation

Focus on Patient Safety and Quality Care - just culture definition - just culture attributes (5) - national pt safety goals example - IOM - QSEN - IPE collaboration

• Just Culture- Reporting Just Culture Attributes • Transparency • Blamelessness • Accountability • Understanding that human error is inevitable • Non-Punitive • National Patient Safety Goals - identification of the pt by 1. Name, 2. DOB, 3. MRN# • IOM (institute of medicine) Competencies-Patient Centered Care • QSEN-Quality & Safety education in Nursing • Collaboration-Inter Professional-SBAR (situation, background, assessment, recommendation)

Pre-Operative Assessment - psychologic - past medical history (why is this important w anesthesia) - degree of surgical risk

• Level of anxiety, knowledge • Past medical and surgical history ----A specific question related to surgery: Have you had anesthesia, if so, have you or a close relative had any problems with anesthesia? To assess the risk for malignant hyperthermia (genetic disorder, affecting men more than woman) • Pain level • Degree of surgical risk - ---- If someone is having surgery and they have multiple comorbidities such as: age, obesity, HTN, DM... the length of surgery can increase surgical risk. (Spinal surgeries, for example)

Central Venous Catheter: Implanted Port (Port a Cath) - length of use - reason for use - patient's who receives this catheter - type of needle used - nurse training - nurse intervention before administering meds

• Long term use - Home therapy. Implanted ports are used most often for patients receiving chemotherapy. These patients are immune-compromised making them highly susceptible to infections. • Subcutaneous port placed under subcutaneous pocket, requires accessing- Huber needle • When it is not being used, you cannot really see it. Nurses can access it but it requires training. They can use a Huber needle. Aspirate before you give meds. • Minimal care

Focus of Nursing Care in the Immediate Postoperative Period

• Maintaining ventilation and circulation - airway • Monitoring oxygenation and level of consciousness - circulation • Preventing shock • Managing pain/anxiety - pain • Preventing complications • Maintaining safety when you receive the pt from the OR, complete an assessment

Complications from General Anesthesia - Malignant hyperthermia (treatment with ___) - overdose - unrecognized hypoventilation - complications of specific anesthetic agents - complications of intubation

• Malignant hyperthermia; treatment with dantrolene - genetic disorder, so there is a familial tendency. Assess incidence in first degree relative. MH is a chain reaction of symptoms (a syndrome) triggered in susceptible individuals by commonly used general anesthetics and, possibly, some other drugs. The symptoms include a greatly increased body metabolism, muscle rigidity and high fever. Associated with certain types of gases, associated with certain types of anesthesia. If there is a risk, they will not use the specific gases associated with malignant hyperthermia. Dantrolene is thought to reduce muscle tone and metabolism by preventing the ongoing release of calcium from the storage sites in muscle (the sarcoplasmic reticulum). In MH, intracellular calcium levels are elevated and therefore dantrolene counteracts this abnormality. • Overdose - related to unrecognized hypoventilation. Monitor oxygen and carbon dioxide. • Unrecognized hypoventilation - can also occur when the pt emerges post op. • Number 1 assessment post op is airway • Complications of specific anesthetic agents - shivering increases your need for oxygen. Nausea is also caused, so we pre-medicate. • Complications of intubation - seen in general anesthesia which requires an advanced airway

Chronic Illness - definition - outcome - associated with what % of healthcare cost - related factors - goal for caring for a pt with a chronic illness - education type - example for pt with COPD

• Medical condition that produces signs/symptoms within a variable time period • Runs a long course, only partial recovery • Associated with 70% of all health care costs in the US. • Associate with factors such as stress, smoking, sedentary lifestyle (1/3 of Americans are overweight or obese) • For a pt with a chronic illness the goal is to minimize the s/s and improve quality of life • Involves in depth and longitudinal pt education • Ex. Goal: minimize triggers for a pt with COPD, trigger examples include: Infection, skin infections, stress, smoking, weather

Administering Regularly Scheduled Medications - Drugs for certain conditions often allowed with a sip of water before surgery: 4

• Medical physician and anesthesia provider should be consulted for instructions about regularly taken prescriptions before surgery. • Drugs for certain conditions often allowed with a sip of water before surgery: • Cardiac disease • Respiratory disease • Seizures • Hypertension

Extent of Surgical Procedure - minimally invasive* (adv.; what does the surgeon normally consent to?) - endoscopic (type of procedure (2); can be in conjunction with ____ technique) - open (consequences) - simple (limited to ___) - radical* (removing a _____ surgical area)

• Minimally invasive: Fiberoptic endoscopes, smaller incisions, customized instrumentation, robotics. Ex. Laparoscopic surgery. Advantages: recovery time is lessened and so is surgical time --> When a surgeon consents, they consent for both minimally and open traditional approach if needed. • Endoscopic: Diagnostic as well as therapeutic; can be used in conjunction with "open" technique; uses natural body opening or porthole incision • Open: Traditional opening of body cavity, more extensive surgical approach, might produce more postoperative pain, longer recovery • Simple: Limited to defined anatomic location • Radical: Involves dissection of tissue and structures beyond immediate operative site. Ex. Radical mastectomy. Removing a large surgical area. There's also radical head and neck.

Nursing Informatics: - NANDA - NIC - NOC

• NANDA Taxonomy: Provides the framework for nursing diagnostic terminology. • NIC: Provides standardized classification of nursing interventions • NOC: Provides standardized outcomes reflecting patient status after nursing interventions

Implementing Dietary Restrictions - NPO (purpose) - time food is restricted before surgery - who to notify

• NPO: Patient advised not to ingest anything by mouth for 6 to 8 hours before surgery: • NPO status notify UAP, dietician and pt! o Decreases the risk for aspiration. o Patients should be given written and oral directions to stress adherence. o Surgery can be cancelled if not followed.

Fluid Replacement Therapy: Crystalloids Isotonic Solutions - 2 most common solutions - purpose - complications - contraindications - only solution to be used with ____ products

• NS (0.9%), Ringers lactate, D5%W* (but will be treated hypotonic, acts as a hypovolemic solution) Intracellular & extracellular concentration are equal. No movement in or out of the cell. Same concentration as plasma • Used to increase circulation intravascular volume • Complications: circulatory overload • Contraindications: circulatory overload, ringers lactate in alkalosis & liver failure -- Lactated Ringer's should not be given to pts w kidney failure, bc it contains K+ and may lead to hyperkalemia, or high K+ levels. Lactated Ringer's should not be used in pts with liver disease, bc they can't break down the lactate in the solution. Pts with lactic acidosis or alkalosis should also not be given Lactated Ringer's, which can change the electrolyte balance in the body • Only solution used with blood products

Treatment of Hypercalcemia - infusion - type of diuretic used - drug to decrease GI absorption of Ca++ - Ca++ chelator's used - drugs that inhibit Ca++ resorption from bone (2)

• Normal Saline infusions / maybe diuretics (only loop, not thiazides) -- 0.9 NS (sodium chloride) given bc sodium increases kidney excretion of calcium. -- Thiazide diuretics are discontinued and replaced with loop diuretics (furosemide), which enhance the excretion of calcium • Corticosteroids to decrease GI absorption • Plicamycin (Mithramycin) - is a calcium chelator (binder). Drug that blocks the PTH gland, decreasing calcium. • Phosphate administration - inhibit calcium resorption from bone • Calcitonin - inhibit calcium resorption from bone Treat cause

Hypermagnesemia - #1 cause is _____ - does what to the muscle (respiratory, DTR, cardiac- 2 conditions; CNS)

• Number 1 cause is renal failure • Others include high magnesium intake • Can lead to muscle weakness, mostly worry about diaphragm leading to respiratory distress • Decreased DTR's • Cardiovascular: slowing of the rate, leading to brady-dysrhythmias including heart blocks. Pt's with severe hypermagnesium are in grave danger of cardiac arrest • CNS changes result from depressed nerve impulse transmission. Pt's may be drowsy or lethargic. Coma may occur if the imbalance is prolonged or severe.

Aging classifications - fastest growing subgroup

• Older adult age starts at 65 yrs of age • 65-74 young old • 75-84 middle old • 85-99 old old à the fastest growing subgroup, the group that's growing the highest in terms of age • >100 elite old

Acute Illness - definition - outcome - education

• One caused by a disease or condition that produces sign/symptoms soon after exposure to the causative agent • Short course • Full recovery or abrupt death • Involves limited pt education

Hypomagnesemia - etiology - found in what type of patient's - to what to nerve transmission - what will happen to DTR - s+s of muscle - what clinical signs may be present/ what other low electrolyte level normally occurs at the same time? - associated with what kind of arrhythmia? (characteristics on ECG) - nurse intervention w pt

• People who are malnourished and alcoholics • Normally magnesium inhibits nerve impulse transmission from nerve to nerve or from nerve to skeletal muscle. Decreased levels of mag increase impulse transmission making muscles more hyperexcitable. The pt will have hyperactive DTR's, numbness and tingling and painful muscle contractions. • Positive chvostek's and trousseau's signs may be present, because hypomagnesium may occur with hypocalcemia • Associated with Trousseaus de Point arrhythmia. It is a form of multifocal or polymorphic ventricular tachycardia. Appearance is known as a spindolin (short long short long). Check the pt and make sure they have a pulse. You can have a pulse or can be pulseless with vtach. Treatment includes administering magnesium.

Peripherally Inserted Midline Catheters - positioning landmark - which vein to use - dwell time - used for what/for how long (examples) - NOT to be used for (3 things) pH/mOsm - what is used at bedside to ensure positioning - what kind of technique should be used - if using a double lumen midline cath, what special precaution should you take?

• Peripherally inserted catheter with the tip terminating in proximal portion of upper extremity at or below the level of the axilla. • Basilic vein preferred over cephalic. • Dwell Time 2-4 weeks - it can stay in place longer. • Used for fluids/drug therapy given longer than 6 days and up to 4 weeks like antibiotics, heparin, steroids and bronchodilators. • Peripheral infusates only • Not to be used for TPN or vesicants (pH between 5-9 and osmolarity <600 mOsm/L) • Not used to draw blood from it • U/S is used at bedside • Sterile technique • When using a double-lumen midline cath, do not administer incompatible drugs simultaneously through both lumens because the blood flow rate in the axillary vein is not high enough to ensure adequate hemodilution and prevention of drug interaction in the vein

What is a PICC Line - where does the tip terminate - dwell time - solutions that can be given - what test verifies its positioning - nursing intervention

• Peripherally inserted central catheter with tip termination in the superior or inferior vena cava • No established dwell time (weeks sometimes months, indicated for someone who needs extended therapy) • Any solution is appropriate • X-Ray verification of tip location is required • Patient considerations

Post anesthesia Care - phase I - phase II

• Phase I encompasses care of the patient from emergence from anesthesia until physiologically stable, including return of protective reflexes and motor function. • Phase II begins with the return to baseline level of consciousness, patent airway with upper airway reflexes, manageable pain, and stable pulmonary, cardiac, and renal functioning. Pt is in the PACU. • Phase III practice settings include 23-hour observation suites, in-hospital units, and recovery care centers within the hospital or community. Nursing care continues until the patient completely recovers from anesthesia and surgery and is ready to resume activities of daily living.

Impaired Skin Integrity and Impaired Tissue Integrity

• Plastic adhesive drape • Skin closures, sutures and staples, nonabsorbable sutures • Insertion of drains • Application of dressing • Transfer of patient from the operating room table to a stretcher

Perioperative Nursing - 3 phases - AORN

• Preoperative Phase • Intraoperative Phase • Postoperative Phase • The Association of Perioperative Registered Nurses- AORN

Nursing interventions for the patient undergoing surgery might include:

• Preventing and reducing complications related to prolonged immobility • Promoting electrical, chemical, physical, and environmental safety in OR - fires in the OR are a real risk. Oxygen increases the risk for a rife. Pt's receiving general anesthesia are receiving high flow oxygen. They have a grounding device. Moderate humidity is maintained. • Monitoring and maintaining patient core temperature • Monitoring fluid volume balance • Monitoring and maintaining aseptic technique • Teaching patient/family perioperative routines

Surgical Team: Some members of the team are scrubbed in and sterile - primary ______ - surgeon's assistant: - scrub nurse: - circulating nurse: (who is it, responsibility) - anesthesiologist and anesthetist

• Primary surgeon - • Surgeon's assistant(s) - other physicians, advanced nurses • Scrub nurse - scrub techs, not usually RN's. Is scrubbed in and sterile, within the sterile field, passing instruments to the surgeon. • Circulating nurse - must be an RN. Not sterile. Their role is documenting, assessment of the pt, medications, getting supplies/people/making calls. Responsible for watching everything and making sure sterility is not broken, help correct sterility. Also account the equipment before the procedure starts and after before the surgical wound is closed. Documents EBL (estimated blood loss). • Anesthesiologist and anesthetist - CRNA

Isotonic Fluid Excess (Hypervolemia) - definition - too much ___ not enough ____ - failure of the _______ to eliminate sodium and water - #1 cause of FVE (+o/t factors that contribute) - what happens to ECF w excessive water retention - what type of treatment can cause / contribute to excess?

• Proportional gain of both sodium and water in the ECF, or... Too much input or not enough output •Failure of the kidneys to eliminate sodium and water o renal failure is the #1 cause of FVE, also heart failure, and long term steroid use • If excessive water retention occurs, ECF becomes hypotonic •Intravenous therapy with isotonic solutions can cause or contribute to extracellular fluid excess - dec. urine specific gravity: 1.010 to 1.030 - dec. hematocrit: (men) 38.8-50%; (women) 39.9-44.5%

Vascular Access Device - purpose - types (2 peripheral, 4 central)

• Purpose: to provide an access route for the administration of parental fluids and medications Types: o Short Peripheral venous catheters - peripheral o Midline catheters - peripheral o Peripherally insert CVC - central, tip of cath is in a central vein o Non Tunneled/Tunneled CVC - central o Implanted Ports - central o Hemodialysis Catheters - central

Pre-Operative Assessment - renal status - GI status - Neuro status - hematologic status - endocrine status (2 diseases to keep in mind) - immunologic - nutrition (surgery depletes which 3 vitamins that are needed for healing and blood clotting) -- what does a rally pack contain? which pt receives a rally pack?

• Renal Status - kidney function affects the excretion of drugs and waste products, ex. Anesthesia. • Gastrointestinal status - how long has the pt been NPO • Neurological Status - at higher risk for delirium • Hematologic Status • Endocrine Status - besides DM, also thyroid disease • Immunologic - is the pt immunocompromised? • Nutrition - may require supplements post-op. Surgery increases metabolic rate and depletes potassium, vitamin C, and B vitamins, which are needed for wound healing and blood clotting. More prone to poor nutrition: older adults and alcoholics. Alcoholics are started on a rally pack for IV supplements: thiamine, vitamin B, folate, which turns fluorescent yellow.

Immediate Respiratory Complications

• Respiratory complications are the leading cause of morbidity and mortality in the immediate postoperative period. • Immediate respiratory complications that might occur include: • Airway obstruction - if ET tube is still in place, secretions can be an obstruction. If it was removed, swelling and edema can be an obstruction. Pt can be experiencing stridor. Described as a high pitched crowing sound. Call RPR. • Hypoxemia - early sign is a change in mental status. Assess RR, o2 sat, ABG. • Aspiration • Laryngospasm - as a result of intubation/extubation. Stridor is what you note.

Positioning following spinal and epidural anesthesia

• Return of sympathetic nervous system tone: gradually elevate head and monitor for hypotension • Epidural or spinal anesthesia number 1 complication is hypotension. You gradually elevate the head of the bed and monitor their BP.

Additional Respiratory Complications Cardiovasvular complications GI Complications Fluid, Electrolyte, and Acid-Base Balance

• Risk factors for respiratory complications include chronic obstructive pulmonary disease (COPD), smoking, advanced age, and obesity. • Atelectasis - incentive spirometer, cough, deep breathing and early ambulation • Pneumonia • Pulmonary embolus Formation of clots (deep vein thrombosis, DVT): Risk factors include history of DVT, clotting abnormalities, immobility, obesity, type of surgery. To minimize DVT, place STD's. • Nausea and vomiting: Occur in 25%-30% of surgical patients. Drug of choice is Zofran. • Abdominal distention • Paralytic ileus - no bowel sounds, abd is distended. Increases risk for vomiting and aspiration. • Stress ulcer - concern with pt's on steroids. Require PPI. • Abdominal compartment syndrome • Intake and output • Hydration status • IV fluids • Acid-base balance • Tachy and hypotension, use isotonic fluid NS.

Nursing diagnoses for the patient undergoing surgery may include:

• Risk for perioperative-positioning injury - related to positioning • Risk for injury - due to medication • Risk for imbalanced body temperature • Risk for imbalanced fluid volume - deficit is most common in the post of pt, related to EBL caused by surgery • Risk for infection • Gerontologic Considerations

Principles of Surgical Asepsis - scrubbed persons function_____ - sterile drapes - surgical scrub should take how long - preoperative skin preparation reduces

• Scrubbed persons function within a sterile field; gowns and gloves provide a barrier to transfer of microorganisms from person to surgical wound. • Sterile drapes create a sterile field and impede movement of microorganisms from a nonsterile to sterile area. • All items used in sterile field are sterile. • Sterile field is monitored and maintained during movement of persons and instruments. • Surgical scrub reduces the number of resident bacteria. Should take 3-5 minutes. • Preoperative skin preparation reduces risk of postoperative wound infection.

Intravenous Therapy: Older Adult Care - skin care - vein and catheter selection - cardiac and renal changes (what are they at risk for? why are they at risk for it? assess for___)

• Skin care - skin loses elasticity, it is more fragile. Fewer nerve endings, decreased ability to feel pain. • Vein and catheter selection - avoid fragile skin and small, tortuous veins on the back of the hand, select the initial IV site higher on the arm. • Cardiac and renal changes - Older adults are at risk for renal complications, due to decreased GFR and fluid overload related to IV fluids. Assess for crackles, JVD, edema.

Four Stages of General Anesthesia: - which stage is induction - which stage is dangerous/not expected outcome - emergence

• Stage 1—analgesia and sedation, relaxation o called induction, when you are inducing the anesthesia and begins when the pt is on the table. Decrease external stimulus during this phase. • Stage 2—excitement, delirium • Stage 3—operative anesthesia, surgical anesthesia • Stage 4—danger o Pt may be over anesthetized or experiencing complications. Not an expected outcome of anesthesia. • Emergence—recovery from anesthesia o Surgery is over and pt is being emerging from anesthesia. Reorient the pt.

What is the purpose for infusing 0.9% Saline IV ? - improve volume in which fluid compartment? - solution has same _____ as plasma - used in which kind of patient's

• Tonicity! • Purpose: improve intravascular volume! 0.9% saline - aka NS, is an isotonic solution, meaning same tonicity as the plasma, so that fluid should remain intravascularly. • Use in someone who is in hypovolemic shock or dehydration.

Regional Anesthesia - definition - nerve block - spinal block - epidural block

• Type of local anesthesia that blocks multiple peripheral nerves in a specific body region • Nerve block - into a nerve or group of nerves, limited use. Also used a lot for pain management, such as carpal tunnel. • Spinal block - injected into the subarachnoid space. Purpose is to depress the nerve impulses below the level of the injection. Commonly used for labor and delivery. • Epidural block - inject directly into the epidural space.

Assessment of Patients - Intravenous Therapy - 2 factors going into verifying MD orders - other factors

• Verify MD orders- Solution and rate D5NS infuse at 100ml/hr • Verify right patient • Calculate infusion rate: gtts/min or pump • Intake/Output • Site assessment- infiltration, phlebitis, infection • Monitor for complications of therapy- fluid overload, electrolyte therapy

Considerations to Anesthesia

• WHO Safety Checklist - also known as a time out performed at the beside to verify right patient, right procedure and right location of surgery. • Bloodless Medicine - religious/nonreligious reasons does not want blood for significant blood loss. If an elective surgery they can donate autologous donation. Other option is erythropoietin to stimulate the bone marrow and production or RBC's. Blood salvaging techniques where blood is reinfused. • Latex Allergies - banana's, kiwi, avocado's.

Potential Complications Related to Wounds

• Wound healing: Factors include advanced age, nutritional status, vascular disease, diabetes • Hemorrhage: Most likely to occur within 48 hours postoperatively; might be related to sutures or small vessel leakage. Seen with a change in mental status, lab values H & H, vital signs. Tachy with hypotension. • Infection: Factors include hematoma, foreign body, dead space, hypothermia • Dehiscence and evisceration: Usually occur 3-10 days postoperatively; separation associated with technical factors, obesity, coughing, infection • Pt's who take long term steroids can diminish immune response.

CVC Management - imaging test to confirm placement / rule out _______ - run what type of solution with vein _________ until position is confirmed - single or multi-lumen catheter -- distal lumen infuses: -- middle lumen infuses: -- proximal lumen infuses: - length of treatment - assessment - complications (3 and their s+s)

• X-ray to confirm placement - location in superior vena cava and rule out pneumothorax. Run isotonic solution KVO (keep vein open) until placement confirmed Single lumen or multi-lumen catheter Distal lumen-infuse blood or fluids Middle lumen- for PN (parental nutrition) Proximal lumen- infuse meds or fluids Recommended for short term treatment • Assess insertion site for s/s infection and pain • Assess for blood return • Assess and prevent complications: • During insertion: Pneumothorax - can puncture the lung. That is why CXR is always ordered. Labored breathing, tachypnea. Accessory muscle use, asymmetrical chest expansion. Auscultation - decreased/absent breath sounds. • Arterial puncture - they can accidentally puncture an artery and the blood return will be quick and bright red. • Arrhythmias - if the cath goes a little too far into the right atrium, causing a premature ventricular tachycardia.

Hyperkalemia Findings - ECG - when its caused by kidney failure (BUN, Cr, pH, HcT, HgB)

• presence of a U wave, associated with recovery or repolarization of papillary muscles. Seen in both hyper and hypokalemia. • Prolonged PR interval - longer impulse conduction time between the atria and ventricles • Tall, peaked or "tented" T wave • P wave is flat or absent • QRS is wide Hyperkalemia caused by kidney failure occurs with elevated serum creatinine and BUN, decreased blood pH and normal/low hct and hbg.

Isotonic Fluid DEFICIT (Hypovolemia/Dehydration) - definition - hypovolemia definition - examples of hypovolemia - febrile diaphoresis : range of amount lost, range of minimum urine output - most common type of fluid loss? compartment is important for determining ____? - what happens to ICF during fluid loss? - what is stimulated? - who is at risk for FVD and why

•Proportional loss of both sodium and water from ECF •Hypovolemia is a decreased intake or increased output •Ways to lose fluid: GI most common: vomiting, diarrhea, NG tube for suction; Blood loss; Insensible fluid loss: we cannot account for! Skin, lungs and stool oEx: diaphoresis due to a fever, having a trache --> Can lose up to 500 mL - 1L a day oThe minimum amount of urine per day needed to excrete toxic waste product is 400 - 600 mL. • No change in osmolality (no fluid shift, fluid is lost only from the eCF space. There is no shift of fluids between spaces, so the ICF volume remains normal.) Extracellular fluid loss is by far the most common type of fluid volume deficit, important for determining treatment. • Book says: fluid is lost only from the extracellular fluid space eCF, including both intravascularly and interstitial spaces. There is no shift between fluids between spaces, so the intracellular ICF volume remains normal. • Stimulates thirst center, ADH, and retention of both water and sodium • Older adults are at risk for FVD because their thirst reflex is diminished, can also be due to possible medications (diuretics) they're taking or functional abilities. Pediatric pt's are also at risk.

Sodium (Na+) - normal range - predominant electrolyte in _____ - "where sodium goes _____ ______" - transmission of (3 processes)

•Sodium is the predominant electrolyte in ECF. Controls water distribution. •Sodium imbalances are usually associated with parallel changes in water loss or gain. "Where sodium goes, water follows". •Transmission of skeletal muscle contraction, cardiac contraction, and nerve impulse transmission.

PRIMARY Factors Regulating Water in the Body - thirst (stim by (2 causes); causes_____; population at risk) -ADH (stim by (2 causes); causes ____; other factors that cause release of ADH) - RAAS

•Thirst: Stimulated by factors associated with water loss and extracellular osmolality; causes oral fluid intake. Thirst response diminished in older adults, so they're at greater risk for developing dehydration. •Antidiuretic hormone (ADH): Stimulated by decreased blood volume or increased serum osmolality; causes reabsorption of water. Main other factors that can trigger the release of ADH from figure: narcotics, stress and anesthetic agents... Thirst, ADH and RAAS all increase blood volume.