Nursing Skills exam 3

Before surgery:

-adress anemia -discontinue anticoagulants and anti platelets

immediate care

-assessment (resp., card.(vitals), CNS (response and stimuli), fluid status, wound status, pain, general condition)

malnourishment risk factors

-fluid and electro imbalances -slow wound healing -infection

kidney and liver risk during surgeries

-fluids and electrolyte imbalances -metabolism and excretion of drugs -wound healing

heart diseases risk during surgeries

-hemorrhage -hypovolemic shock -hypotension -thromboplebitis

Post operative care

-immediate -ongoing care

Wound complications

-infection -hemorrhage -dehiscence(wound separates) and evisceration(protrusion) -fistula formation

ongoing care

-promote health, teach care for when pt goes home

respitatory depression risk during surgeries

-resp depression -post-op pneumonia

obesity risk factors

-resp, card, and positional & GI problems

NG tube

-short term use less than 4 weeks

pts at risk

-smokers, obese -malnourished, anticoagulant users -infected wounds, cough, vomit

lymphocyte normal range

1,500-4,000

Albunim normal range

3.4-5.4

Glucose normal range

70-110 mg/dL

Fat soluble vitamins

A, D, E, K

water soluble vitamins

B and C

moderate sedation/analgesia

Conscious sedation or procedural sedation. Used for short term and minimally invasive procedures.

factors affecting wound healing

Dessication- dehydration Maceration- overhydration Necrosis- death of tissue Biofilm- a thick grouping of microorganisms

wound stage 4

Full-thickness tissue loss with exposed bone, muscle, or tendon

ICOUGH for atelectasis

I - Incentive Spirometry. C - Coughing & deep breathing. O - Oral care (brush teeth and use mouthwash 2x a day). U - Understanding (pt and staff education). G - Getting out of bed at least 3x a day. H - HOB elevation.

Stages of Anesthesia

I: Induction; the period between administration of anesthesia and loss of conciousness II: maintenance: that point until end of procedure III: Emergence: pt wakes and ready to leave OR

major surgery

Involves extensive reconstruction or alteration in body parts; poses great risks to well being

Norton Scale

Physical and mental condition, activity, mobility, and continence

minor surgery

Procedure without significant risk; often done with local anesthesia, lesions and deformities

Cold therapy

Promotes vasoconstriction, increases blood viscosity, decreases metabolism of tissues, has local anesthetic effect - Decreases muscle tension - should not be applied for longer than 20 minutes or reflex vasodilation can occur -increases comfort

Heat therapy

Promotes vasodilation, decreases blood viscosity, increases metabolism of tissues, increases capillary permeability - should not be applied for longer than 20-30 minutes, or reflex vasoconstriction and tissue congestion can occur, accelerates inflammatory response

RYB

Red - protect Yellow - cleanse Black - debride

constructive

Restores function lost or reduced as result of congenital anomalies (cleft palate repair)

regional anesthesia

Temporary interruption of nerve conduction, is produced by injecting an anesthetic solution near the nerves to be blocked.

evisceration

The most serious complication of dehiscence. The wound completely separates, with protrusion of viscera through the incisional area.

ablative

To remove a diseased body part (amputation, appendectomy)

Intentional wounds are.....

Trauma that occurs during therapy such as venipuncture or tumor removal.

purulent drainage

WBC's, liquified dead tissue debris, dead and live bacteria (dark yellow, or green) [green=Pseudomonas aeruginosa]

eschar

a dry, dark scab or falling away of dead skin, typically caused by a burn, or by the bite of a mite, or as a result of anthrax infection.

unintentional wounds

accidental, occur from unexpected trauma (stabbing, gunshot)

Skin Assessment

acute:every shift long-term: admission and weekly for 4 weeks home: every visit

Waterlow Scale

age and gender (sex), build and weight, continence, skin type, mobility, nutrition, and special population-specific risks

basal metabolism

amount of energy required to carry out involuntary activities of the body at rest

Ischemia

an inadequate blood supply to an organ or part of the body, especially the heart muscles.

closed wound

an internal injury with no open pathway from the outside (falls, assault)

biofilm

antibiotic resistance

maturation

begins 3 wks after injury, scar is formed "remodeling stage"

decreased hematocrit risk factors

bleeding, anemia

hyper/hypovolemia risk factors

cardiac problems

adrenal steroids risk factors

cardiovascular collapse from abrupt withdrawal

atelectasis

collapsed lung; incomplete expansion of alveoli

serous drainage

composed of clear, serous portion of the blood and from serous membranes

hydrolyzed formula

composed of partially digested protein peptides and are referred to as free amino acids used for clients who have partially functioning GI tract or those who have an impaired ability to digest and absorb foods most provide 1.0-1.2 cal/mL High calorie formulas provide 1.5-2.0 cal/mL

diagnostic

confirm diagnosis (breast biopsy)

How to treat wounds:

cover wound with sterile towels moistened with sterile 0.9% sodium chloride and notify the provider -place in low fowler's position and cover abdominal contents -npo

"-ine" histamines

decrease gastric acidity & volume as well as oral secretions

Desiccation

dehydration crust forms over site and delays healing

trauma

delayed or inability to heal

Surgery based on purpose

diagnostic, curative, preventative, ablative, palliative, reconstructive, transplantation, constructive

pressure

disrupts blood supply and delays healing

chronic wound

do not progress through stages of healing; healing impeded (diabetes, injuries)

surgery based on urgency

elective, urgent, emergency

diuretics risk factors

electrolyte imbalances

wound stage 1

erythma and intact skin

Narcotic analgesics

facilitate sedation and relaxation

wound stage 3

full thickness tissue loss with visible fat

Anesthesia types

general, regional, local, conscious sedation

Wound complications: hemorrhage

hematomas form(clotted blood)

Phases of healing

hemostasis and degeneration, inflammation, proliferation and migration, remodeling and maturation

parenteral nutrition

hypertonic -formulas with all macros

endocrine risk during surgeries

hypoglycemia, acidosis -slow wound healing -post-op cardiovascular complications

Hemostasis

immediately after injury, blood clotting begins

edema

inadequate oxygen supply and nutrients

tranquilizers risk factor

inc. hypotensive effects

Regional Anesthesia: Spinal

injection into cerebrospinal fluid in subarachnoid space [lower abdominal, pelvic, hip, knee surgeries]

Regional Anesthesia: Epidural

injection into the epidural space [anorectal, vaginal, perineal, hip, lower extremity surgeries]

standard formula

intact proteins and contains balanced proportion of macronutrients

Wound Classification

intentional, unintentional, open, closed, acute, chronic

open wound

intentional/unintentional -portal of entry is open (incisions and abrasions)

peripheral pn

isotonic -dextrose and amino acids

inflammatory

lasts 2-3 days, WBC move to wound and attract fibroblasts that help fill up the wound -inc tempo and general malaise

Trendelenburg position

lying on back with body tilted so that the head is lower than the feet

lithotomy position

lying on back with legs raised and feet in stirrups

surgery based on degree of risk

major and minor

anticoagulant risk factors

may precipitate hemorrhage

what are vitamins needed for?

metabolism of carbs, protein, and fats

what environment is best for wound healing?

moist environment

slough

moist, stringy or mucinous, white/yellow tissue that tends to be loosely attached in clumps to the wound bed

overweight risk factors

obstructive sleep apnea -reduced resp fxn -GERD -infection

infection

occupies all energy and delays healing

fistula

often result from an infection that developed into abcess

maceration

overhydration, softening and breakdown of skin from prolonged exposure to moisture and changes in PH

wound complications: dehiscence & evisceration

partial or total separation of wound layers

wound stage 2

partial thickness skin loss or blister

preoperative phase

period of time from when the decision for surgical intervention is made to when the patient is transferred to the operating room table

postoperative phase

period of time that begins with the admission of the patient to the postanesthesia care unit and ends after follow-up evaluation in the clinical setting or home

intraoperative phase

period of time that begins with transfer of the patient to the operating room area and continues until the patient is admitted to the postanesthesia care unit

elevated nitrogen risk factors

potential kidney problems

the perioperative phases

preoperative, intraoperative, postoperative

Wound Complications: Infection

purulent drainage, pain, redness, swelling

"-pam" sedatives

reduce anxiety

proliferation

regenerative epithelial cells form across the wound, granulation tissue 24-48 hrs

palliative

relive or reduce intensity of illness but its not curative (colostomy)

antibiotics risk factors

respiratory paralisis

Braden Scale

sensory perception, moisture, activity, mobility, nutrition, friction and shear

urgent surgery

surgery that is not an emergency, but must be done within a reasonably short time frame to preserve health 24-48 hrs

elective surgery

surgery that is recommended but can be omitted or delayed without catastrophe

emergency surgery

surgery that must be performed immediately to save the person's life or a body organ

general anesthesia

the blockage of all body sensations, causing un-consciousness and loss of reflexes. -inhaled or IV

transplantation

to replace organs or structures that are diseased or malfunctioning (kidney,liver, or cornea)

topical and local anesthesia

used on mucous membranes, open skin, wounds, burns Sometimes used in conjunction with other types of anesthesia

acute wound

usually heal within days to weeks risk of infection is low

Risk of anesthesia

• Intubation • Atelectasis • Pleural fluid • Increased sputum production • Pleural effusion • Arrhythmias • pneumonia Halothane