PPC2 Exam 4

Hypertension is a major risk for what potential diseases?

- Stroke - Myocardial infarction (Heart attack) - Heart failure - Kidney dysfunction

Complications and reactions of Conscious sedation

-Airway obstruction-Insert airway and suction -Respiratory depression-Admin O2 and reversal agents like Narcan and Romazicon -Cardiac arrhytmias-Set up 12 lead ECG, provide antidysrhythmics and fluids -Hypotension- fluids and vasopressors -Anaphylaxis- admin epinephrine

Transfer from OR to PACU

-Anesthesiologist transfers with circulating nurse and they give report -PACU nurse immediately performs a full body assessment *Priority to Airway, breathing, circulation (ABC) -Maintain Airway and ventilation *Keep airway in place if client is comatose *Adm humidified O2 *Suction secretions if client unable to cough *Assist with TCDB and splinting *Encourage use of IS *Reposition every 2 hours and ambulate early and regularly

What nursing interventions would you implement for someone in HTN crisis?

-Check BP every 5-15 minutes -Assess neuro, PERRLA, LOC -Monitor EKG -Provide oxygen and watch 02 sat.

Aldrete Scoring System

-Determines readiness for discharge from recovery room (PACU) to the surgical floor ****score for test 8 or above***** *stable VS including ABC's *no evidence of bleeding *return of gag, cough, swallow reflexes *wound drainage is minimal *urine output at least 30 ml/hr *adequate pain control *gastrointestinal discomfort (N/V)

discharge teaching

-Medications- purpose, adm guidelines, adverse effects -Activity restrictions-driving, stairs, lifting, sex -Special tx instructions-cath care, wound care, use of assistive devices Emergency contact and when to contact provider

Non-opioids

-NSAIDs and acetaminophen -can be added to opioids for intense pain -also have antipyretic and anti-inflammatory properties -most uses acetaminophen- no more than 4gm/day -monitor for salicylism (tinnitus, vertigo, and hearing acuity) prevent GI upset-GIVE FOOD/ANTIACIDS! Monitor for bleeding (Long term use)

RN duties

-Nursing assessment and judgment -Planning of nursing care and evaluation of the patient's response to the care given, -implementation of patient care that requires judgment -Medications, IVs/blood administration, and sterile administration procedures -Teaching -Evaluation

Teaching points for Diuretics

-Older adults to rise slowly -potassium sparing agents-decrease intake of foods high in potassium and to report weakness and irregular pulse (hyperkalemia) -Loop and thiazide agents-eat foods high in potassium and monitor levels

PQRST pain assessment

-Precipitating or palliative -Quality or quantity -Region or radiation -Severity scale -Timing

Top priority pt's

-Respiratory patients: Air compromise, choking, asthma, chest trauma -Cardiovascular patients: Cardiac arrest, shock, hemorrhage -Neurological patients: Major head injury, unconscious, unresponsive, seizures

What would you teach a patient with high BP to do?

-Restrict sodium intake -Reduce weight -No alcohol, tobacco, smoking -Exercise -relaxation

5 rights of delegation

-Right Task: -Right Circumstances; -Right Person; -Right Direction/Communication; -RIght Supervision

Nurse delegates tasks based on:

-The needs and condition of the patient, -Potential for harm-Stability of the patient's condition -Complexity of the task -Predictability of the outcome -Abilities of the staff to whom the task is delegated

NANDA Nursing Dx: Post-Op

-acute pain -risk for infection -risk for injury -risk for deficient fluid volume -ineffective airway clearance -ineffective breathing pattern -Self care deficit: bathing, hygiene, dressing, groom, --toileting -Ineffective health maintenance and disturbed body image

Indirect delegation

-approved list of activities or tasks

lab tests for secondary hypertension -

-creatinine clearance for kidney disease -Urinary test for the presence of catecholamines -chest x-ray for cardiomegaly -ECG to test for ventricular hypertrophy

Thiazide diuretics

-decrease calcium secretion so no kidney stones -usually the drug of choice for patients with uncomplicated HTN may cause decreased libido and decreased sexual activity in men can worsen gout

Non-pharmacological pain relief

-decrease stress -mind-body practices (yoga, Chiro) -cognitive approaches (relax, meditation) -natural products (herbs, oils) -elevation of extremities -reposition frequently -cutaneous stimulation (tens, heat, cold, massage, accupuncture) -reduction of pain stimuli-smooth bed, clean, not laying on anything

advantages of delegation

-improved efficiency, productivity, and efficiency. -job enrichment

delegation decision-making grid

-level of client acuity; -level of UPA's capability; -level of licensed nurse capability; -potential for harm, -frequency of performance of skill; -level of decision making, -ability for self care

opioids

-moderate to severe pain -Routes: Transdermal, transmucosal, buccal routes

beta blockers end in... -

-olol

Myths of pain

-patients who abuse substances overact to discomfort -pat. w/ minor illnesses have less pain than those with severe physical alteration -administering analgesics regularly leads to drug addiction -the amount of tissue damage in an injury accurately indicates pain intensity -health care personnel are the best authorities on the nature of pat.'s pain -psychogenic pain is not real -chronic pain is all psychological -clients who are hospitalized experience pain -clients who can not speak, do not feel pain

What causes secondary HTN?

-pheochromocytoma (tumor of adrenal gland), bushings syndrome, medications, renal disease

what are the barriers to effective pain management?

-physical dependence -addiction -drug tolerance cognitive impairment-speak another language

monitor and manage pain

-prevent vs. prn -monitor every 30 min for pain relief and resp rate -PCA, epidural, intraehcal infusions -Side Effects: Nausea, urinary retention, constipation -Analgesia before ambulation

lifestyle changes in hypertension -

-reduce sodium intake -reduce weight if obese -use alcohol sparingly -exercise 3-4 days/week for 40 minutes -decrease stress -stop smoking

safe tasks for unlicensed staff

-take vitals; -help with ambulation to bathroom

Control systems that maintain BP -

-the arterial baroreceptor system -regulation of body fluid volume -the renin-angiotensin-aldosterone system -vascular autoregulation

Who are you going to delegate to?

-unlicensed assistive personnel; -liscensed practical nurse; -ancillary personnel; ; -other registered nurses

Direct delegation

-verbal direction of activity or task

standardized scale for less than 7 year old

0-2 in categories of face, legs, activity, cry, and consolability

lego pain assessment tool

1-10 > or equal to 7 years old

An obstetric nurse is floated to a medical unit to care for a group of acutely ill clients. The charge nurse should assign which group of clients to the float nurse? 1. A client with a three-day-old total knee replacement, a client who is postoperative for colectomy, and a client who is post-operative for hysterectomy. 2. An older adult client with dehydration, a client with atrial fibrillation, and a client just admitted with hip fracture. 3. A client with an old cerebrovascular accident, a client with a three-day-old hip replacement, and a client with diabetic ketoacidosis. 4. An older adult client with pneumonia, a client with an exacerbation of asthma, and a client who has below knee amputation. -

1. A client with a three-day-old total knee replacement, a client who is postoperative for colectomy, and a client who is post-operative for hysterectomy. Rationale: The float nurse from the obstetrics unit can be assigned clients who have abdominal surgery, since the nurse likely has experience working with clients having cesarean section. The nurse can also be assigned clients whose conditions are relatively stable. Clients who have acute conditions compounded by chronic health problems are more complicated, and are better assigned to nurses with experience on the medical-surgical unit. Also, older adult clients can have fluctuations in status, placing them at higher risk for complications, which is not an ideal situation for the float nurse.

A nurse is delegating care of clients to the certified nursing assistant (CNA) and licensed practical nurse (LPN). Which tasks should the nurse give the CNA and LPN? 1. CNA: Measure vital signs; LPN: Give oral medications on assigned clients. 2. CNA: Change a non-infected dressing; LPN: Administer IV piggyback medications. 3. CNA: Ambulate a client who had a CVA; LPN: Assess two clients. 4. CNA: Measure vital signs; LPN: Complete a head-to-toe assessment on a newly admitted client. -

1. CNA: Measure vital signs; LPN: Give oral medications on assigned clients. Rationale: The scope of practice and most job descriptions for CNAs include vital signs. It is within the scope of practice for the LPN to administer oral medications. In some facilities, CNAs are allowed to change dressings; however, the scope of practice for LPNs does not allow them to administer IV medications. CNAs are allowed to ambulate clients; however, LPNs should not assess clients. CNAs are able to measure vital signs but LPNs do not complete admissions because it involves assessment.

OLDCARTS (pain assessment for in/out patient HPI)

1. Onset 2. Location 3. Duration 4. Character 5. Aggravating/associated factors 6. Relieving factors 7. Temporal factors 8. Severity

A nurse has delegated a venipuncture to an unlicensed assistant (UA) who has been off orientation for five days. The UA reports, "This client has a large, raised red area where the needle was inserted." The nurse's subsequent assessment reveals a hematoma in the venipuncture area. What elements of delegation have been breached? Select all that apply. 1. Task 2. Circumstance 3. Communication 4. Supervision 5. Skill -

1. Task 4. Supervision 5. Skill Rationale: The nurse assigned a task at which the UA evidently was weak, and did not provide supervision. The nurse has delegated a venipuncture to a UA who may or may not be comfortable providing the skill. Though the task is permissible in general, venipuncture is not the right task for this UA.

Pre-hypertension BP

120-139/80-89

Stage 1 hypertension

140-159/90-99

when assessing pain after giving IM pain medicine, what time frame do you re-assess?

15-20 minutes

A registered nurse (RN) who is the charge nurse for the shift is making assignments for the day. Which client should be assigned to the licensed practical nurse (LPN)? 1. A client with sickle-cell anemia requiring pain medications every three hours. 2. A three-day postoperative client who will be discharged tomorrow morning. 3. A 76-year-old client newly admitted with pneumonia and type 2 diabetes mellitus. 4. A client who received chemotherapy for leukemia and has a hemoglobin of 6.4 grams/dL. -

2. A three-day postoperative client who will be discharged tomorrow morning. Rationale: The three-day postoperative client who will be discharged tomorrow is stable. The client's outcomes are almost met. The LPN could provide the care for this client. A client with sickle-cell anemia who requires pain medications every three hours needs frequent observations and assessments. Because of the RN's ability to problem-solve and think critically, this client should be assigned to a registered nurse. A 76-year-old client with a newly admitted with a chronic condition, type 2 diabetes, exacerbated by an acute condition, pneumonia, is at risk for changes in status and require frequent assessment. A client with leukemia who has a hemoglobin of 6.4 grams/dL might need a blood transfusion, and has unpredictable outcomes. The RN should care for clients with unpredictable outcomes.

The registered nurse (RN) is assigned to five clients for the shift. Which tasks are best delegated to the licensed practical/vocational nurse (LPN/LVN)? Select all that apply. 1. Repositioning a nasogastric tube on a client who has had a small bowel resection. 2. Irrigating a urinary catheter on a client admitted from a skilled nursing facility. 3. Rechecking vital signs on a 40-year-old asymptomatic client with a BP of 100/64. 4. Changing a dressing on a client with a diabetic foot ulcer in the metatarsal area. 5. Administering red blood cells to a client with a hemoglobin of 10.2 grams/dL. -

2. Irrigating a urinary catheter on a client admitted from a skilled nursing facility. 4. Changing a dressing on a client with a diabetic foot ulcer in the metatarsal area. Rationale: The scope of practice for LPNs allows them to irrigate urinary catheters and change dressings on diabetic ulcers. While LPNs are allowed to irrigate nasogastric tubes, the RN should reposition the tube if it is necessary. The routine measurement of client with a BP of 100/64 does not require the skills of an LPN; a UAP could do this instead. Blood administration should not be delegated to an LPN due to the complications that could arise during the transfusion; rather, it is within the scope of practice of the RN.

A client is experiencing respiratory distress. Respirations are 32 breaths/min and shallow. The client is positioned in an orthopneic position, with a heart rate of 118/min and a blood pressure of 90/40 mm Hg. The client is pale and confused. Which task should the nurse delegate to the charge nurse? 1. Head-to-toe assessment 2. Placement of a second IV site 3. Application of oxygen 4. Overhead page the respiratory therapist (RT) -

2. Placement of a second IV site. Rationale: The charge nurse should be used to complete a task within the RN's scope of practice, such as starting an intravenous line, while leaving client assessment to the assigned nurse. The assigned nurse should complete a head-to-toe assessment. The nurse assigned to the client knows more about the client than other nurses on the unit do, and can determine a change in the client's status. The application of oxygen is a task for the nurse assigned to the client. Given the information provided in the scenario, the nurse should apply the oxygen immediately to rectify low oxygen levels. The unit secretary could page RT to the room stat for assistance.

The staff nurse who is in charge of the medical-surgical unit for the shift is receiving four admissions. The emergency department is sending a client with hypertension and an exacerbation of heart failure, and a client who has pneumonia and a history of diabetes mellitus. The post-anesthesia care unit (PACU) is transferring a client who had a total abdominal hysterectomy and a client who underwent hip replacement. If the staff consists of two RNs (one on orientation) and two LPNs, what assignment would be appropriate? 1. The RN on orientation will be assigned the postoperative client who underwent hip replacement. 2. The experienced RN will be assigned the postoperative client who underwent hip replacement. 3. An LPN will be assigned the client with pneumonia and history of diabetes. 4. An LPN will be assigned the client with the abdominal hysterectomy. -

2. The experienced RN will be assigned the postoperative client who underwent hip replacement. Rationale: Of the answer options, the best option is that the skilled RN should get the postoperative client with the hip replacement and the abdominal hysterectomy. Postoperative clients are critical clients due to the risk for hypovolemia and shock. The experienced nurse should receive the surgical clients. The RN on orientation should care for the clients with medical conditions such as CHF, hypertension, and diabetes. In this case, the LPNs should assume duties such as vital signs and assisting with ADLs.

The delivery of care system on a medical floor is team nursing. On wing A, there is a registered nurse (RN), licensed practical/vocational nurse (LPN/LVN), and an unlicensed assistant person (UAP) to care for eight clients. Which tasks would be best delegated to the LPN? 1. Vital signs and assessment of a newly postoperative client. 2. Wound care and oral medications for all clients. 3. Vital signs and bed baths on all eight clients. 4. Physical assessments on two young, stable clients. -

2. Wound care and oral medications for all clients. Rationale: The LPN may check vitals and give bed baths, but the skill set of the LPN is better utilized in providing wound care and medications for the clients. Due to scope of practice the RN should check vital signs and perform assessment of the postoperative client. The scope of practice of a UAP involves completion of tasks, so the UAP should check vital signs and complete bed baths on the clients. Physical assessment is within the scope of practice of the RN.

when assessing pain after giving PO pain medicine, what time frame do you re-assess?

20-30 minutes

Which task would not be appropriate for the registered nurse (RN) to delegate to a licensed practical nurse (LPN) or unlicensed assistive personnel (UAP)? 1. Instructing the LPN to reinforce teaching of the RN's assigned clients prior to discharge. 2. Assigning UAPs to complete vital signs and document and report changes to the RN. 3. Asking the UAP to assess and evaluate the client response to IV pain medication. 4. Instructing the LPN to remove a dressing from a postoperative client's abdominal wound. -

3. Asking the UAP to assess and evaluate the client response to IV pain medication. Rationale: The decision to delegate should be consistent with the nursing process (appropriate assessment, planning, implementation, and evaluation). The person responsible for client assessment, diagnosis, care planning, and evaluation is the registered nurse. The LPN can reinforce teaching previously performed by the RN. Assistive personnel may perform simple nursing interventions, but the RN remains responsible for analyzing the data and the client outcome. The LPN can change a dressing.

A nurse plans to delegate some responsibilities of client care to a licensed practical nurse (LPN). Which task should the nurse delegate to the LPN? 1. Assessment of a newly admitted client. 2. Admission of a postoperative client. 3. Dressing changes for a client with wounds. 4. Assist a client with ambulation and AM care. -

3. Dressing changes for a client with wounds. Rationale: The best choice is to assign the LPN to change the client's dressing. The registered nurse should perform all assessments. The registered nurse is skilled in assessment and in providing care to those with unpredictable outcomes. The nursing assistant may ambulate the client and provide AM care.

After receiving the intershift report, the registered nurse (RN) has many tasks to complete during the next 12 hours. Which tasks would the nurse delegate to an unlicensed assistant person (UAP)? Select all that apply. 1. Flushing a nasogastric tube on a client who has had a colectomy. 2. Irrigating a clogged urinary catheter on an older adult client. 3. Rechecking vital signs on a 30-year-old client with a BP of 100/60. 4. Changing a dressing on a client with an infected diabetic foot ulcer. 5. Measuring and recording hourly urine output for a client who underwent nephrectomy. -

3. Rechecking vital signs on a 30-year-old client with a BP of 100/60. 5. Measuring and recording hourly urine output for a client who underwent nephrectomy. Rationale: The UAP can measure vital signs and report the findings to the RN. The UAP can measure and record the urine output, although the RN would need to make further assessments about the client's status. The RN should irrigate the nasogastric tube and irrigate the urinary catheter as these are not in the UAP's scope of practice and job description. A client with an infected wound should have the dressing changed by the RN for assessment of effectiveness of wound therapy and complications.

The registered nurse (RN) must delegate care of an assigned client to an unlicensed assistive person (UAP) for the shift. Which client would be best to delegate to the UAP? 1. A client who would benefit from talking about the recent death of her husband. 2. A client with a urinary drainage catheter and nasogastric feedings who is on bedrest. 3. A client with an ostomy who has persistent problems with leakage. 4. A client who was transferred from the critical care unit 3 days ago and is ambulatory. -

4. A client who was transferred from the critical care unit 3 days ago and is ambulatory. Rationale: Factors to consider when delegating care include complexity of task, problem-solving innovation required, unpredictability, and level of client interaction. The ambulatory client is best to delegate because this client is likely to be stable with a low level of unpredictability. The client who recently lost her husband would benefit from pro- fessional communication with the RN and requires a high level of client interaction. The client receiving enteral feedings and is immobilized represents a more complex client, who is better assigned to a licensed nurse. The client with a leaking ostomy would benefit from problem-solving innovation and is best cared for by the RN.

A nurse is preparing for the shift, and makes a list of delegated tasks for the unlicensed assistive person (UAP). Which task should the nurse delegate to the UAP? 1. Feeding a client who was admitted with dysphagia from cerebrovascular accident. 2. Monitoring drainage from a chest tube on a client with a hemothorax. 3. Rechecking vital signs on a client whose blood pressure is 190/102. 4. Repositioning a client with severe weakness caused by multiple sclerosis. -

4. Repositioning a client with severe weakness caused by multiple sclerosis. Rationale: The UAP is qualified to reposition a client with multiple sclerosis who has severe weakness. Due to the risk for aspiration, the nurse should feed the client with dysphagia. The nurse should monitor drainage from a chest tube for characteristics of exudate being removed from the client's thoracic cavity. When a client has an elevated or low blood pressure, the nurse should recheck and assess the client for validity of information and changes in status.

when assessing pain after giving iv pain medicine, what time frame do you re-assess?

5-10 minutes

minimum score for graduation to move patient

8

Stage 2 hypertension

>160/>100

Reversal agents

A drug used to lessen or abolish the effects of anesthetic agents or adjuncts, and which is therefore used to "wake" the patient after sedation or anesthesia

malignant hyperthermia

A hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs. diagnosed with muscle biopsy. Dantrolene given prophylactically for susceptible patients

dependence

A physical reaction in the absence of a drug. A state in which there is a compulsive or chronic need

Critical thinking

A rational reasoning process that involves applying knowledge, skills, attitudes, and values for the purpose of making a decision that affects patient care

In caring for patients with pain and discomfort, which task is most appropriate to delegate to a nursing assistant? A. Assist the patient with preparation of a sitz bath B. Monitor the patient for signs of discomfort while ambulating C. Coach the patient to deep breathe during painful procedures D. Evaluate relief after applying a cold application

A- because they are just accompanying; other tasks need to be done by the RN

The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision? A. Observe how well the patient performs pursed-lip breathing B. Plan a nursing care regiment that gradually increases activity intolerance C. Assist the patient with basic activities of daily living, D. Consult with the physical therapy department about reconditioning exercises

A-Because they are just observing, the pt has already been taught to do this most likely so you are not teaching.

After an anesthesiologist delivers nitrous oxide with a face mask, which is the priority assessment? A.Oxygen saturation B.Blood Pressure C.Heart rate D.Temperature

A. Oxygen saturation Assessment of oxygenation is the priority with administration of a medication with CNS and respiratory depression effects. (ABC)

Prioritizing

ABCs, Maslow's Hierarchy of Needs, or nursing process; look at what pt needs now, not in a couple hours First-level priority problems: Life-threatening, Immediate problems, Remember "ABCDs" Second-level priority problems: Change in LOC, acute pain, abnormal values Third-level priority problems: Later problems, Lack of knowledge, activity or rest

UAP role

Activities of daily living, Grooming and bathing, Dressing and toileting, Ambulating, Feeding, Positioning, Specimen collection, Vital signs, Intake and output

conscious sedation

Administration of sedatives and/or hypnotics to the point where the client is relaxed enough that minor procedures can be performed without discomfort, yet the client can respond to verbal stimuli, retains protective reflexes (gag), is easily arousable and most importantly, Independently Maintains a Patent Airway

STERILE FIELD / OR

Appropriate surgical hand washing technique Enter OR with hands higher than elbows, always keep hands above waist when donning sterile gown and gloves Area of attire sterile- 2 inches below neck to waist and from wrist to elbow Observe surgical field and look for breaks in sterile technique

ABCDE of pain management

Ask/assess pain, Believe patient, Choose pain control options, Deliver interventions, Empower patient.

Best practices for patient safety & Care for Hypertensive Urgency/Emergency

Assess: Severe headache, extremely high BP, Dizziness, Blurred vision, Shortness of breath, nosebleed (epistaxis), severe anxiety Interventions: Place in semi-fowlers position administer Oxygen start IV .9% saline slowly Administer IV beta blocker or cardene iv when stable monitor BP every 5-15 min until diastolic is below 90 and not less than 75 then monitor BP every 30 minutes to ck it doesn't drop too low observe for neurologic and cardio vascular complications

Calcium Chanel Blockers Teaching

Avoid grapefruit-enhances action of drug

A 52-year-old male is scheduled for a left below the knee amputation today. The pre-operative nurse is completing a checklist which should include ALL of the following except: A.Procedure Consent B.Cremation Consent C.Anesthesia Consent D.Genetic Testing Consent

B.Cremation Consent

monitoring equipment needed for conscious sedation

Basic Requirements for Monitoring Sedated Patients: Blood Pressure, Pulse Oximetry, and EKG.

Therapeutic Communication Lessons

Be empathic to how the patient is feeling and what their needs are from you as the nurse. You are the patient's advocate, especially so when the patient in under anesthesia. Communication is so important in the OR. Multiple disciplines in one room. Always be aware of the surroundings and safety concerns.

When does perioperative nursing occur

Before, during and after a procedure

Injectable anesthetics

Benzodiazepines, etomidate, propofol, ketamine, Odanestron & fentanyl

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit? A. A 58-year old on airborne precautions for tuberculosis (TB) B. A 68-year old just returned from bronchoscopy and biops C. A 72-year old who needs teaching about the use of incentive spirometry D. A 69-year old with COPD who is ventilator dependent

C- Because this patient is the most stable

A patient with uterine cancer is scheduled for a hysterectomy the following day. The patient informs the nurse that she does not want to go through with the procedure. Which step should the nurse take? A.Inform the client that the surgery is necessary and that there is nothing to worry about B.Notify the surgeon that the client is refusing surgery and needs to be sedated C.Inform the surgeon of the client's statement so that the surgeon can talk with the client D.Note the client's statement on the chart and reassess the client

C.Inform the surgeon of the client's statement so that the surgeon can talk with the client The provider performing the procedure has the responsibility to obtain the client's consent. The nurse has the responsibility as a client advocate.

Which is the most dangerous possible adverse effect of inhalation anesthetics? A.Hypertension B.Increased Intercranial pressure C.Malignant Hyperthermia D.Atrial tachycardia

C.Malignant Hyperthermia Malignant hyperthermia is a life-threatening risk with inhalation anesthesia (for example, succinylcholine). Prompt administration of 100% oxygen, dantrolene (skeletal muscle relaxant), and cooling blankets is vital to survival.

A 17 y.o. male is having a knee arthroscopy performed. After administration of midazolam (Versed), the nurse notices the client's blood pressure has dropped to 86/40 mm Hg and his HR is 134 beats/min. Which should the nurse anticipate after informing the surgeon of the vital sign changes? A.Administering Naloxone (Narcan) B.Administering Morphine C.Giving a 500 mL NS bolus D.Stopping the procedure

C: Giving a 500 ML NS bolus A fluid bolus is appropriate to raise the client's BP to maintain adequate cardiac output and tissue perfusion. Morphine would further drop BP and pulse. Administering narcan would also reverse the desired effects of versed and compromise the effectiveness of the anesthesia. Stopping the procedure would not address the BP.

Lab tests for Surgical patients

CBC, CMP, BLOOD CHEMISTRY, COAG (PT/INR AND PTT), EKG, XRAYS, CT SCANS, MRI

Under RN, the LPN can:

Cares for stable patients (ex: flesh-eating disease is not stable), Updating initial RN assessment, Reinforce teaching from a standard care plan, Updating initial assessment, (State specific) Sterile procedures, initiate-maintain IVF lines, blood transfusions, IV push medications, IV antibiotics, inserting tube feeds, and so on

Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team? A. Evaluating the patient's complaint of chest pain B. Monitoring laboratory values for changes in oxygenation C. Assessing for symptoms of respiratory failure D. Auscultating the lungs for crackles

D- because LPN's don't evaluate or assess

A 68-year-old client is undergoing an endoscopy, which will require conscious sedation. Which findings in her history indicate the need for further assessment? A.Bee sting allergy B.HTN C.GI bleed D.COPD

D. COPD ABC issue- COPD poses a risk for a possible airway compromise

difference between dementia and delirium

Dementia: slow, steady, progressive Delirium: fast, rapid, acute onset, reversible

RISK FACTORS FOR ANESTHESIA

FAMILY HISTORY OF MALIGNANT HYPERTHERMIA RESPIRATORY DISEASE (HYPOVENTILATION) CARDIAC DISEASE (DISRHYTMIAS, CARDIAC OUTPUT) GASTRIC CONTENTS (ASPIRATION) PRE-OP USE OF ETOH AND ILLICIT DRUGS

Different measures of pain scales

FLACC scaling and is appropiate when they cant tell us verbally numbers, faces

What causes primary HTN?

Family history, smoking, A.A., age, obesity

Reversal drug for benzodiazepines (versed and valium)

Flumazenil

What supplements have been used for hypertension? but what problem is there with one of them?

Garlic and co enzyme Q10, but garlic can damage the liver and cause bleeding if you have surgery

Behavioral responses of acute pain

Grimacing, moaning, flinching, and guarding

example of major surgery

HEART SURGERY, ABDOMINAL resection, amputation, brain surgery

What can K sparing diuretic cause?

Hyperkalemia

Nursing role-Initial assessment after transfer from pre-op area

ID, physical, psychosocial, and cultural finding for risks during the operative procedure Advanced directives must be honored in the OR The patient, DPOA will decide whether to maintain, suspend, or modify the DNR orders during surgery and anesthesia. If order is suspended, must decide and document when to reinstate Perioperative nurse responsibility to support patient's EOL treatment choices and the right to refuse tx

local anesthesia

INHIBITS NERVE CONDUCTION UNTIL DIFFUSSED INTO CIRCULATION- COMMON FOR MINOR PROCEDURES

First thing to do in hypertension crisis

IV site

Loop diuretics (furosemide)

Inhibit Na , Chloride, and water reabsorption in the Loop of Henle and promote potassium secretion so you have more

lateral position

Lateral- lying on side; table may be bent in middle Risk for injury to dependent brachial plexus and dependent common peroneal nerve, PU over greater trochanter of femur; potential interference with cardiac action b/c of shift in heart position

lithotomy position

Lithotomy- lying on back with buttocks to edge of table; thighs and legs placed in stirrups simultaneously to prevent muscle injury; head and arms secured SCD's and/or Antiembolism stockings needed to prevent thrombosis; risk for vein compression in legs, increased intrabdominal pressure, injury to obturator and femoral nerves b/c of thigh flexion; injury to peroneal nerve r/t fibular neck resting against stirrups; risk for acute hypotension when legs are lowered

regional anesthesia

Loss of sensation in an area of the body supplied by sensory nerve pathways.

essential hypertension, primary hypertension

Most common type, not caused by an existing health problem -Family History -Ethnicity -Smoking -Older than 60 or postmenopausal -hyperlipidemia -excessive sodium and caffein -overweight/obesity -inactivity -excessive alcohol -low potassium, calcium or magnesium intake -excessive and continuous stress

Anesthesia Complications

Myocardial depression: Bradycardia, hypotension, cyanosis, edema Anaphylaxis: Cardiac failure, allergic symptoms, abnormal VS Malignant Hyperthermia (esp with use of succinylcholine: Tachycardia, tachypnea, hypercarbia, dysrhythmias ANS system blockade (epidural or spinal): Hypotension, bradycardia, nausea, vomiting CSF leakage (spinal and epidural): Headache

UAP can delegate to

NO ONE

who administers conscious sedation

Only qualified providers: Anesthesiologists, CRNAs, attending physicians, or RNs under the supervision of one of the above providers

Who can RN's delegate to?

Other RN's, LPN's, and UAP

somatic pain

Pain that originates from skeletal muscles, ligaments, or joints.

Diagnostic surgery

Performed to determine cause of symptoms or verify diagnoses

Elective Surgery

Planned scheduled surgery nose job, cosemetic

RN responsibilities

RN can delegate tasks but not the nursing process. ex: the nurse can tell the NA to take vitals but not to evaluate the reading; that's their responsibility

Palliative surgery

Relieves symptoms without curing disease Ex: make it easier for cancer patient to breath

Preventative surgery

Removal of a body part with the intent to prevent disease/illness

Curative surgery

Removal of diseased part, repair damaged or malformed area, removal of early stage tumor

Cosmetic surgery

Repair, re-construct to improve appearance deformities Ex: clef palate, nose job

5 rights of delegation

Right task Right person Right circumstances Right directions/communication Right supervision and evaluation

NANDA DX intraoperative risks

Risk for aspiration Ineffective protection Impaired skin integrity Risk for perioperative-positioning injury Risk for impaired body temperature Ineffective tissue perfusion Risk for deficient fluid volume

What is the role of the circulating nurse

Safety of the client most important - Positioning - Site prep - Safety checks - Physiological monitoring - Medication Admin - Monitoring Sterility - Documentation - Management of catheters and specimens

Genetic Testing Consent

See it with pregnancy, young children allows to look at genetic abnormalities or issues

SOCRATES Pain Assessment

Site Onset Character Radiates Associated symptoms Time/duration Exacerbating/relieving factors Severity

cultural considerations of pain

South Africa-pain taboo in men, associated with weakness, lack of honor, and courage. Folklore teaches african children to deal with pain in stoic, resilient manner Hispanic Americans: men endure pain in order to support and provide for family. women endure pain to care for and nurture family Patients may not seek care because of these

What type of pain scale do you use with clients greater than 7?

Standardized pain scales

Stage 1 Hypertension BP levels

Systolic: 130-139 Diastolic: 80-89

Stage 2 Hypertension BP levels

Systolic: 140 or higher Diastolic: 90 or higher

Hypertensive Crisis levels

Systolic: Higher than 180 Diastolic: Higher than 120

Normal Blood Pressure Levels

Systolic: Less than 120 Diastolic: Less than 80

local anesthesia

Topical-applied to skin or mm Local infiltration- injected directly into tissues where incision is to be made ex: •Procaine and lidocaine •May give with epinephrine to cause vasoconstriction

Pain is subjective and first person. T/F

True-pain is what the patient says it is

LPNs can delegate to

UAP and LPN's

urgent surgery

Unexpected, urgent surgery don't won't condition to get worse

Hypertensive Urgency vs Emergency

Urgency: After remeasuring BP it is still just as high, but the patient is not experiencing other symptoms of target organ damage Emergency: Pt is experiencing symptoms of target organ damage

paralytic ileus

Usually temporary paralysis of intestinal wall that may occur after abdominal surgery or peritoneal injury and that causes cessation of peristalsis; leads to abdominal distention and symptoms of obstruction

orthostatic hypotension -

a 20 mmHg decrease in BP when changing from lying to sitting

conscious sedation

a decreased level of consciousness in which the patient is not completely asleep. CAN MAINTAIN AIRWAY AND RESPOND TO VERBAL STIMULI OR LIGHT TACTILE STIMULATION. ex: VERSED

visceral pain

a poorly localized, dull, or diffuse pain that arises from the abdominal organs, or viscera causes referred pain: felt in another body location separate from the stimulas

guided imagery and visualization

a type of treatment in which a patient follows verbal prompts to envision a specific, peaceful location in detail, distancing him- or herself from any pain or stress the patient is currently experiencing

regional nerve block

also called nerve block; the injection of a local anesthetic near the nerve root Spinal: injected in subarachnoid space CSF Epidural: Injected in epidural space in the thoracic or lumbar area of spine Bier: IV injection into an extremity following mechanical exsanguination with a tourniquet Peripheral: Injection into a specific nerve for analgesia and anesthetic use

hypertensive crisis -

an elevation in blood pressure greater than 180/120

acupunture

application of extremely fine needles to specific sites in the body to relieve pain

To prevent circulatory complication in the immediate post-operative period for a patient who has had a cholecystectomy, which nursing action is of the highest priority? a.Administer pain medication b.Apply anti-embolism stockings c.Encourage coughing and deep breathing every two hours d.Monitor vital signs every hour until stable

b.Apply anti-embolism stockings

For people younger than 60 years, the desired BP is -

below 140/90

For those 60 years and older, the desired BP is -

below 150/90

ACE inhibitors decrease hypertension by -

blocking the action of ACE at it attempts to convert angiotensin I to angiotensin II (a vasoconstrictor)

angiotensin II receptor antagonists decrease BP by -

by blocking the binding of angiotensin II to receptor sites in the vascular smooth muscle avoid foods high in potassium-can cause hyperkalemia

An 18-year-old patient is brought to the ED. The patient is unconscious, hypotensive and has sustained serious orthopedic injuries in an MVA. Which is true of the treatment for this patient? a.Next of kin needs to be notified prior to treatment beginning b.Advanced directive and durable power of attorney should be reviewed prior to treatment c.The life-threatening injuries warrant immediate emergent treatment d.The client can be treated after consent is given

c.The life-threatening injuries warrant immediate emergent treatment

Teaching points for beta blockers

can cause fatigue, depression, and sexual dysfunction should be used with caution for diabetics-glucose production may be affected monitor for orthostatic hypotension-can contribute to falls and confusion

examples of ARBs -

candesartan, losartan, valsartan

examples of ACE inhibitors -

captopril, lisinopril, enalapril

BP is a product of -

cardiac output and peripheral vascular resistance

neuropathic pain

caused by abnormal or damaged nerves different than nociceptive pain because it is an abnormal processing of painful stimuli

adrenal-mediated hypertension -

caused by primary excess of aldosterone, cortisol, and catecholamines

calcium channel blockers lower blood pressure by -

causing vasodilation and decreasing HR

Addiction

compulsive drug craving and use Substance abuse disorder consequences don't matter

opiods adverse effects

constipation orthostatic hypotension urinary retention nausea and vomiting sedation respiratory depression

ex of ablative surgery

cutting out or removing something appendectomy colectomy

calcium rich foods include:

dairy products, lentils, fish w/ fine bones, dried fruits, nuts, chocolate, cocoa, Ovaltine potatoes, spinich

would you see dementia or delirium post operatively

delirium surgery doesn't cause dementia symptoms go away as meds wear off

quality of pain refers to

describes or discription of pain ex: sting, ache, dull

Inhaled anesthetics

desflurane (Suprane) sevoflurane (Ultane) isoflurane (Forane) nitrous oxide Rate of elimination depends on pulmonary ventilation and blood flow to lungs****intervention

mixed pain

difficult to categorize fibromyalgia, HIV, Lyme disease

What drugs do you use to manage hypertension first?

diuretics if pt. does not respond to lifestyle changes

Most common side effect of ACE inhibitors -

dry, nagging cough

adjuvants/co-analgesics

enhance effects of non-opioids helps alleviate other manifestations that aggravate pain (depression, szs, inflamation) useful for treating neuropathic pain

drugs that can cause secondary hypertension -

estrogen, glucocorticoids, mineralocorticoids, sympathomimetics, cyclosporine, and erythropoietin

Cushing's syndrome -

excessive glucocorticoids are excreted from the adrenal cortex causes secondary hypertension

ex of emergency surgery

failure of an organ post operative hemorrhaging life or death

supine position

flat on back with arms at side, palms down, legs straight with feet slightly separated Most commonly used position; venous pooling in legs may result from reduction of venous pressure

cremation consent

for cremation can't change mind after it or undo it

DVT (deep vein thrombosis)

formation of a blood clot in a deep vein of the body, occuring most commonly in the legs or thighs

anesthesia consent

got by anesthesia dr. nurses do not get it just make sure it is in the chart

secondary hypertension -

hypertension cause by disease or drugs -kidney disease -brain tumors -pregnancy -drugs (contraceptives*women* and corticoids)

patients who do not adhere to their medication regimen are at risk for -

hypertensive crisis and organ damage

What can thiazide and loop diuretics cause?

hypokalemia

risk factors for post op complications

immobility anemia hypovolemia older age respiratory disease immune disorder DM coagulation defect malnutrition obesity

Potassium sparing diuretics

inhibit the reabsorption of sodium ions in exchange for K , leaving it in the body

general anesthesia

involves the total loss of body sensation and consciousness induced by anesthetic agents administered primarily by inhalation or intravenous injection

Accountability

is being responsible and answerable for the actions or inactions of self or others in the context of delegation ; need to make sure action was completed safely

Supervision

is the provision of guidance or direction, evaluation, and follow-up by the licensed nurse for the accomplishment of a nursing task delegated to a UAP; need to make sure action was completed

Delegation

is the transfer of responsibility for the performance of an activity from one individual to another while retaining accountability for the outcome

What is the most common cause of secondary HTN?

kidney disease

What is the DASH diet?

low sodium, high K , high Ca diet

cardioselective beta blockers -

lower BP by blocking receptors in the heart and peripheral blood vessels, decreasing HR and myocardial contractility

moderate sedation (conscious sedation) special consideration

make sure they don't get too much oxygen but they are breathing enough on their own

Reversal for narcotics and opioids

naloxone

Procedure Consent

need for all things you do surgically to patient legally binding document protects of the rights of the patient

lab tests for essential hypertension -

no lab tests specifically

sodium intake -

no more than 2400 mg/day, but 1500 mg/day is preferred

which type of pain med is used for mild to moderate pain and moderate to severe?

non-opioid for mild to moderate opioid for severe pain

If patient has versed, what happens when you give them naloxone

nothing, it does not work Naloxone only works on overdoses caused by opioids.

What is perioperative Nursing?

nursing care provided for the patient before, during, and after surgery

procurement procedure:

obtaining organ from an donor

physical assesment/signs and symptoms -

often no symptoms but some patients experience dizziness, fainting, headaches, or facial flushing

calcium channel blockers are most effective in... -

older adults and african americans

Which drug therapy is best for older adults for hypertension?

once a day so they have a lower the risk of them forgetting and not following the drug regimen

chronic pain

ongoing and occurs more than 3 months

which route is best for chronic, nonfluctuating pain?

oral

nociceptive pain

pain from a normal process that results in noxious stimuli being perceived as painful

Break thru pain

pain that is above and beyond the normal level ex: pain 2 out of 10 normally on med but then when it wears off before it is time for next dose or coughs

acute pain

pain that is felt suddenly from injury, disease, trauma, or surgery temporary protective, warns of danger has a direct cause resolved with healing

which route is best for immediate, short-term relief of acute pain

parenteral

prone position

patient lying on abdomen with face turned to one side, arms at sides with palms pronated, elbows slightly flexed; feet elevated to prevent plantar flexion Pt anesthetized in supine position and then placed prone; chest rolls or frame used for support; respiratory excursion decreased; risk for injury to head, eyes, nose and facial nerve, genitalia and breasts

when using loop or thiazide diurectics when should you use caution

patients with diabetes-glucose control affected patients with gout-uric acid retention

Informed consent

permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits.

breakthru pain

person experiences exacerbation of acute pain those with chronic pain can experience Breakthru pain requiring additional pain relief

Example of minor surgery

plastic surgery, cataract, skin removal, lasiks

Positioning

position as ordered pad bony prominences maintain body alignment do not impede circulation and respiratory expansion avoid pressure against skin, bones and nerves change positions at regular intervals

garlic -

potential to reduce cholesterol and hypertension, but can cause liver damage and bleeding

why is the retina assessed? -

reliable indicator of the severity and prognosis of HTN

reconstructive surgery

restore appearance or function due to trauma or illness Ex: Double mastectomy

When do you take blood pressure medicene

same time every day

symptoms of hypertensive crisis -

severe headache, extremely high BP, dizziness, blurred vision, shortness of breath, epistaxis, severe anxiety

Hypertension Guidelines

similar to DASH Diet consume vegtables, fruits and whole grains low fat dairy, poultry, lugumes, fish, nuts, non tropical vegtable oils, limit sweets, sugar-sweetened beverages and red meat lower sodium to no more than 2400 g/day engage in aerobic physical activity 3-4 x/wk for 40 min decrease modifiable factors: smoking/alcohol

PCA pain pump

small frequent dosing insures consistent plasma levels typically morphine & hydromorphone

what type of pain scale do you use with clients 7 and under?

specialized pain scales

what is important to know about the scales of pain

stick with the same scale consistancy

Hypertension patients are at risk for treatments involving ______.

stress

hypertension can cause -

stroke, MI, kidney failure, and death

cutaneous pain

superficial pain usually involving the skin or subcutaneous or connective tissue

Trendelenburg's position-

supine, head and body lowered into head-down position; knees are flexed by "breaking" table Respiratory excursion decreased from upward movement of abdominal viscera; cerebral edema or venous thrombosis possible

emergency surgery

surgery that must be performed immediately to save the person's life or a body organ Ex: bleeding out, post operative issues

problems associated with acute pain

tachycardia, hypotension, anxiety, diaphoresis, muscle tension

Transplant surgery

taking from one and putting it in another

HTN crisis is a risk for..

target organ damage What are some manifestations of HTN crisis? *headache, extremely high BP 240/120, blurred vision, dizzy, disorientation, anxiety, nose bleed, dyspnea

Tolerance

the diminishing effect with regular use of the same dose of a drug, requiring the user to take larger and larger doses before experiencing the drug's effect takes more of med to do the same thing

Assignment

the distribution of work that each staff member is to accomplish on a given shift or work period

Who is the authority on the presence and extent of pain experienced by a client?

the patient

loop diuretics are not commonly used for older adults because -

they cause dehydration and orthostatic hypotension

What is special about general anesthesia

they don't breath on their own

drug of choice for hypertension -

thiazide diuretics

first line drugs used to treat hypertension -

thiazide diuretics, calcium channel blockers, ACE inhibitors, and angiotensin II receptor blocker

delegation (definition)

transferring responsibility for the performance of an activity or task while retaining accountability for the outcome.

example of pain intensity

using the numbers scale ex: 6 out of 10

how to prevent a DVT in a post operative patient

walking sed's-compression stockings

how do you know if you have a paralytic illuis?

zero bowel sounds 5 minutes per quadrant-20 minutes total

Monitor and maintain fluid status

•Adm IV isotonic solutions- (LR,NS) and maintain a patent IV line •Output should equal Intake •Report outputs less than 30 mL/hr •Make sure if no indwelling cath client voids at least 200 mL within 6 hours after surgery •Palpate bladder following voiding to assesss for bladder distention

postoperative nursing assessment

•Airway and respiration-•Patency, rate, rhythm, symmetry, breath sounds, color of mucous membranes •Circulation-•Heart rate, rhythm, BP, capillary refill, nail beds, peripheral pulses •Temperature control-•Malignant hyperthermia, hypothermia •Genitourinary-•Urinary function returns in 6 to 8 hours. •Gastrointestinal-•Anesthesia slows motility •Comfort-•Use pain scale to assess pain.

Evidence bases ways to decrease risk of SSI (surgical site infection)

•Antibiotic therapy within 1 hour prior to surgical incision •Good blood glucose control •Maintain normothermia (norm. body temp) •No shaving

Electrical Safety

•Apply grounding pads appropriately •Check equipment carefully •High risk for Surgical Fires

Monitor for and Prevent Thromboembolism

•Apply pneumatic compression stockings and/or elastic stockings •Reposition every 2 hours and ambulate regularly and early •Administer low-level anticoagulants as prescribed •Monitor extremities for calf pain, warmth, erythema, and edema ***High risk pelvic and abd surgeries

nurse responsibility regarding fluid use and blood loss

•Circulating and scrub nurses perform count of all sponges, equipment, and towels---Min of 3 counts •Circulating nurse reports off to PACU nurse when transferring after the surgery---•Notify of blood loss and any fluid resuscitation

Procedures using conscious sedation

•Endoscopy, LP, and cardioversion •Wound care- suturing, dressing changes, I&D of abscesses, and burn debridement •Minor surgical procedures- dental, podiatric, plastic, and opthalmic procedures; vasectomy •Placement of implanted devices, catheters, and tubes and removal of same •Bone marrow aspiration •Reduction and immobilization of fractures

post-op Incisions and drains- bleeding and infection interactions

•Monitor drainage- sanguinous to serosanguinos to serous •Incision site- pink wound edges, slight edema under sutures/staples, slight crusting of drainage***•Report signs of infection. Redness, excessive tenderness, purulent drainage •Drain sites- monitor with each VS assessment*** Empty as needed to maintain compression •Change dressings as required using sterile aseptic technique (Usually reinforce and surgeon does first change) •ABD binder for obese or debilitated clients •Splinting with position changes •Prophylactic antibiotics as prescribed •Remove sutures in 6- 8 days as prescribed

Older adult concerns

•More susceptible to anesthetic agents than other populations •Meds carefully titrated-Meds carefully titrated to control unwarranted effects, older adults may experience acute memory loss or altered perception after anesthesia. •Airway main priority but cardiac problems arise more quickly •Particular attention to this client since the condition can deteriorate very quickly

bowel function and oral comfort

•NPO until return of gag reflex and peristalsis Risk of aspiration and paralytic ileus •Irrigate NG suction tubes with NS as needed to maintain patency •Provide ice chips and sips of water as permitted •Frequent oral care •Monitor for BS x 4 and ability to pass flatus •Advance diet as tolerated - clear liquids to regular

drugs used in conscious sedation

•Opiods-•Morphine, fentanyl •Anesthetics-•Propofol (diprivan) •Benzodiazepines-•Versed, valium, lorazepam Dosages required for "light sedation" are highly individualized and require careful titration

Malignant hyperthermia risk factors

•Previous experience with surgery •Hx of heatstroke in patient or family •Known muscular abnormalities •CPK level may be elevated (non-specific) •Key assessment- family hx of unexplained death under general anesthesia

ANurse must continuously monitor a client undergoing conscious procedure T/F

•RN must be present to monitor client with no other responsibilities during the procedure •Must remain with the client at all times before, during, and immediately after the procedure

When can nurse discharge from PACU

•Use Aldrete Scoring System- Aldrete score of 8 •Stable VS •No evidence of bleeding •Return of reflexes- gag, cough, swallow •Wound drainage minimal to moderate •UO- at least 30 mL/hr