NURS-334 Exam 1
Nursing Assessment: (preop)
Determine psychological and physiological factors that may contribute to risk with surgery
Vaccine Contraindications
o People think that if they have a sniffle they shouldn't get vaccine or live vaccine but unless they've had an actual fever within 24 hours they are usually fine to get a vaccination o Egg allergy for influenza vaccination
Tertiary Prevention (Restoration/Disease Management)
o Prevent disease progression, preventing long term consequences of a chronic illness or disability, have the disease but want to prevent from having secondary issues or comorbidity from that o Begins after injury or illness, ex: referring pt. to support group, or helping pt. to control BS from DM so they don't get pressure ulcers
Vaccine Information Statements (VIS)
o Put out by CDC and are extensive info and education of vaccine, side effects and when to seek medical care, good guideline when giving vaccines to educate pt. giving the sheet is their consent to receiving vaccine o States side effects and what to expect
Stages of Change
o Transtheoretical Model (also used in health promotion) o Positive reinforcement
Child Learners
o Want to do more assessing with where they are at, what they understand, language level, nonverbals are easy to follow, are open about saying that they don't understand, get on their level, if towering over them not interested in what you are talking about, want them to talk to you, incorporate play, like using a doll to put bandaid on area where they are having surgery-ex,
Immune System
-Compromised = Increased risk for infection, as pt. age the immune system is less effected, worry about elderly during flu, influenza, covid, some meds can suppress immune system -Compromised patients have an increased risk for infection and wound healing
Nervous System
-Evaluation of neurologic functioning, do they have deficits, May be affected by vision or hearing loss -Evaluation of neurological functioning, fine motor skills, gross motor skills
Urinary System
-make sure they can void, Hx of renal disease (for older pt do baseline of renal test) -Hx of frequent UTI, risk for fluid and electrolyte imbalance
The nurse is preparing to discharge a patient from the ambulatory surgery center following an inguinal hernia repair. The nurse delays the release of the patient upon discovering that the patient
A. Had IV morphine 45 minutes ago B. Has an oxygen saturation of 92% C. Has not voided since before surgery** D. Had one episode of vomiting 30 minutes ago
During the administration of any regional anesthetic, it is most important that the nurse:
A. Monitor for ascending neurologic depression and unconsciousness B. Ensure the airway equipment, emergency drugs, and monitors are immediately available** C. Monitor for patients response to the anesthesia, assessing the extent of loss sensation D. Have reversal drugs such as anti cholinesterase agent (e.g. neostigmine (Prostigmin) available in case of respiratory arrest.
Preoperative instruction that is appropriate for all patients include:
A. Techniques of deep breathing and coughing B. Descriptions of the planned surgical procedure C. Physical procedures or preparation required before surgery** D. Withholding of all oral fluids or food after midnight on the day of surgery
While in the PACU, the patient's blood pressure drops from an admission pressure of 126/82 to 106/78 with a pulse change of 70 to 94. The nurse administers oxygen and then
A. increases the rate of the IV fluids. ** B. Notifies the anesthesia care provider C. Performs neurovascular checks on the lower extremities D. Uses a cardiac monitor to assess the patient's heart rhythm.
Diagnosis for Pain and Discomfort
Acute pain, Disturbed sensory perception
Additional nursing assessment questions
Additional nursing assessment: allergies · Current medications o Prescription and over the counter (OTC) o Herbs o Vitamins o Recreational § Drugs § Alcohol § Tobacco o Health Hx o Ask them to bring it all in and be detailed with questions, St. johns' horn, vitamin E, fish oil, garlic, known for thinning blood, inceds have anti platelet, sometimes recommend Tylenol for inceds before procedure instead,
Risk Factors for Health
Age, Gender, Genetics, Physiological Factors, Environment, Lifestyle Behaviors
Catastrophic Events in the OR
Anaphylactic reactions, malignant hyperthermia,
Diagnosis for Alterations in Psychological Function
Anxiety Ineffective coping Disturbed body image Decisional conflict
Potential Alterations in Psychological Function
Anxiety and depression Risks with lack of knowledge, assistance, or resources Confusion and delirium Emergence delirium Postoperative delirium-Increased in elderly Can occur Weeks to months postop
Implementations for Alterations in GI Function
Are they NPO, Ambulate
Surgery (from a safety perspective)
Art and science of treating diseases, injuries, and deformities by operation and instrumentation
Potential Alterations in Respiratory Function Assessment
Assessment · Monitor airway- count resp rate, how hard they are working to breath · Chest symmetry · Respirations-depth, rate · Lung sounds · Oximetry- normal is 95-100% · Sputum- are they spitting up, secretions, coughing
Interventions for Alterations in Integumentary System
Assessment, looking, touching, observing, looking for pressure points -Frequently turning them Frequent assessment Rubbing the skin to improve circulation Early ambulation Wound dehiscence- a separation of the edges (sutures break open, etc) Wound evisceration- protrusion/something popping out of the inscision
Assessment for Potential Alterations in GI function
Auscultate for bowel sounds Ask if they are passing gas
Post Operative Nursing Care
Begins immediately after surgery · PACU- (post anesthesia care unit) located adjacent to OR, usually right across the hall from the suits, its placed close so if need assistance like airway or need other personnel · Limits transportation- pt doesn't have such a long ride and don't need elevator so that its close, primary focus is safety, number one concern after surgery is airway · Provides necessary access to anesthesia and OR personnel
DVT Prevention- Intervention Medications
DVT Prevention: o Heparin- location of choice is abdomen § Subcutaneous- only available § Antidote- protamine sulfate- helps reverse o Coumadin § Route- Oral § Antidote- vitamin K o LMW (low molecular weight) Heparin- sub cutaneous, because low weight don't have to worry about reversing as much o Xarelto- oral o Sometimes don't use any of these and use baby aspirin 81 mg,
Nursing Diagnosis for Alterations in Circulatory Function
Decreased cardiac output Deficient fluid volume Excessive fluid volume Ineffective peripheral tissue perfusion Activity intolerance
Aldrete Scoring System
Developed by nurses to help decide when pt is ready to transition, score of two phases, Used to assess transition from Phase I to Phase II · Discontinuation of anesthesia to return of protective reflexes and motor function A score of 9 or 10 indicates readiness for transfer or discharge to the next phase of recovery, anything less than that they are not ready for transfer
Balanced Options
Different classes of medications used for general- most common type of anesthesia, type of General Anesthesia IV induction agents, Inhalation agents
Evidence Based- Health Screenings
o New knowledge generated by research efforts, know that through research the earlier the screening the better outcomes they have. o Sources o Practice guidelines- general practitioners can look on the websites and realize what level of screening they should recommend for pt. o U.S Preventative Service Task Force (USPSTF), CDC puts out too
Generational Differences
o not every pt. in that generation learns the same, the elderly pop are getting more tech savy as time goes on, can provide a helpful website or webinar
Childhood Obesity
screening indicatedCheck BMI- at school age 6+ Starts age 6+, looking at closer, expect to get younger as seeing obesity happen earlier in children
Intraoperative Care
time period during the surgical procedure, not on the surgical floor but scrubbed in with them, orientation is longer to work in surgery than ICU or critical care because nurse needs to have a unique skill set of anatomy, special procedure, instruments, unique area for nurses to work in · Nursing care requires understanding of surgical procedures · Nurse must keep current on technologies · Maintain asepsis in surgical environment · National Patient Safety Goals · Surgical Care Improvement Project (SCIP)
Learning Needs
§ New knowledge and skills needed to meet goals What you think is important may be different from what patients want to know
Levels of Prevention
Primary Prevention, Secondary Prevention (screening), Tertiary Prevention (Restoration/Disease Management)
Q. Which of the following patients is unable to sign an operative permit?
1. A 15 year old*** 2. An elderly man who is HOH 3. The guardian of a child 4. The parent of a child
Process of Patient Teaching
Learner Characteristics, Generational differences, learning needs, readiness to learn, motivation, stages of change
Integumentary System
are they at risk for skin breakdown/had issues with that? -Risk for skin breakdown, weight, activity
Health Promotion for Children
- Health promotion for children is different from adult because giving the education to the parent -Nutrition, Injury
Respiratory System
- do they have a Hx of pneumonia, upper resp infection, spasm,- affect airway preop and post op, Increased risk for laryngospasm, bronchospasm, SOB, chronic cough
Musculoskeletal System
- have they had Fx, Hx of osteoporosis, etc.
Anaphylactic reactions
- if pt. have never had surgery before they don't know if they are allergic to meds · Manifestations may be masked by anesthesia, induced or accentuated by the anesthetic agent like o Hypotension, tachycardia, bronchospasm, pulmonary edema o These other things can trigger the response, o Ex: come in from construction day and they are overheated it does increase their risk factor for catastrophic event in the OR even with no choice, if trauma to body can increase risk, stress, increases risk for adverse reactions, o Other factors such as trauma, heat, and stress have been implicated as triggers o Usually occurs under general anesthesia but may also occur in recovery
The nurse provides postoperative instructions for an adult patient after cataract surgery. Which written statement, if provided by the nurse, would be most appropriate?
1. "To avoid contamination of the eye, use aseptic technique when applying eye drops." 2. "Conjunctivitis may result if the eye is contaminated with wet or dirty eye patches." 3. "To prevent infection in the eye, wash your hands before changing the eye patch or using eye drops."** 4. "Coughing and bending over can cause increased intraocular pressure, resulting in retinal damage or displacement of the intraocular lens," 3. Because there is no medical language
Which type of anesthesia would most be appropriate for a client with severe COPD who broke their hip?
1. General 2. Epidural/spinal** 3. Local 4. Conscious sedation -Why? Because of the COPD its severe they're not the greatest candidate for general anesthesia and then they have to have an artificial airway, local anesthesia would not be enough for this kind of procedure and conscious sedation is sedation achieved with giving medication
A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?
1. Pain** 2. Hearing Loss 3. The client's culture 4. Motor impairment Pain because it limits the pt. ability to focus
Cervical Cancer Screening
21-65: recommend pap smear every 3-5 years >65: no screening recommended as long as previous test have been negative and not at high risk for cervical cancer (with family Hx) Every 3 years if you don't do HPV screening with it and every 5 years if you do the HPV screening at same time
A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on the affective learning with this client, which of the following interventions should the nurse use?
A. Ask the client to perform a return demonstration of insulin injection. B. Review the action of insulin therapy. C. Explore the client's feelings about dietary modifications** D. Have the client practice blood-glucose monitoring using a glucometer. C. is on the feelings- affective
A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?
A. Attending a class given about tracheostomy care. B. Verbalizing all steps in the procedure C. Performing the procedure independently** D. Asking appropriate questions about suctioning. C. We want them to be able to do it themselves- just because they can tell you about it doesn't mean they can do it correctly
A 68 year old male scheduled for a herniorrhaphy at an ambulatory surgical center expresses concern that he will not have enough care at home and asks if he can stay in the hospital after the surgery. The best response by the nurse is?
A. "Who is available to help you at home after the surgery?" ** B."I'm sure you will be able to manage at home after surgery. It is a simple procedure." C. " We will teach you everything you need to know to be able to care for yourself after surgery," D. "Your health insurance will pay for inpatient care only if complications develop during surgery."
A patient becomes restless and agitated in the post anesthesia care unit (PACU) as he begins to regain consciousness. The first action the nurse should take is:
A. Turn the patient to a lateral position B. Orient the patient and tell him the surgery is over C. Administer the ordered postoperative pain medication D. Check the patients oxygen saturation with pulse oximetry**
During admission of the patient to the holding area or operating room before surgery, the perioperative nurse must:
A. Verify the patient's understanding of the risk of surgery B. Ensure the patients identity with a formal identification** process C. Prepare the skin by scrubbing the surgical site with an antimicrobial agent D. Perform a preoperative assessment with a patient history and physical examination
Interventions for Alterations in Psychological Function
Provide adequate support Listen and talk with patient, offer explanations, reassure, and encourage involvement of significant other Discuss expectation of activity and assistance needed after discharge
Potential Alterations in Urinary Function
Low urinary output first 24 hrs. Increased aldosterone and ADH Medications depress nervous system and make bladder less sensitive to urge to urinate Urine stasis- higher chance of UTI Leading cause of post op infection is having a urinary catheter in
Health People 2020:
Initiative that provides science-based 10-year national objectives for promoting health and preventing disease · Beginning of this was in 1979)- had been around since then but really started in 2000 and then updated o Then Healthy People 2000, 2010, 2020- have framework for 2030 but don't have the overarching goals. o Goals for 2020 are: · Healthy People 2020 "overarching" goals
Before surgery:
Chart review- is important, before pt. is taken to preop holding area and taken off unit need to make sure they have · H & P · Lab- has been completed and reported in chart, healthy pt. that have minor surgery might not have labs, some labs can include... nurse is responsible to have it in chart, don't want the pt. to go have surgery and have some anesthesia and surgeon comes to relax and looks and lab work is not on there and everything needs to be stopped because lab work is not on there. o Urinalysis o CBC o Serum electrolytes o Chest x-ray o ECG · Positioning patient- might need to be in different positions like dorsal recumbent, lateral recumbent, supine · Prepping site- might need to shave hair off or scrub prep on area of body, · These are responsibilities of nurses in OR suite · This information contributes to an understanding of past and present history, cardiopulm status, and potential for infection and other complications
Domains of Learning
Cognitive, Psychomotor, Affective
Communication Within Surgical Team
Communication- is important part of surgical experience, nurses on floor are in preop area need to communicate with OR nurses, and OR nurses need to communicate with PACU nurses, and PACU nurses need to communicate with nurses where pt. is going back to weather outpatient area or admitted into surgical floor in hospital · Situation · Background · Assessment · Recommendation · Use this because otherwise something can be missed/forgotten · The joint Commission (TJC) requires that all health care providers implement a standardized approach to handoff communication. · SBAR is one such form · The preop nurse ensures that complete and accurate hand off occurs every time patient care is transferred to another professional. Ex include transfers of change of shift, surgeon to nurse, and OR nurse to post anesthesia nurse.
Interventions for Alterations in Temperature
Cooling measures- fan, taking off blankets, acetaminophen, cold wash cloth Warming measures- blankets, warmed IV fluids, warmed oxygen
Time Outs/Pause for Cause
During a procedure will call a time out, nurse does this and keeps track of it, everyone for a second stops what they are doing, and they make sure everything is done, they count instruments and sponges- do it after too and make sure they have the right pt, right procedure, etc. Surgical Safety Checklist- part of safety goals and required by JTC bottom line is the provider doing the procedures who is responsible for getting that signature, but the nurse needs to make sure it's done -done prior to starting and during intraop care
Surgical Setting
Elective vs Emergency- like having a surgery fit in schedule vs an emergency that comes in Inpatient vs outpatient- also called ambulatory care - Same day admission Inpatient vs. Ambulatory -Ambulatory (same day or outpatient)-
Classification of Anesthesia
Even though RN don't give this they are responsible for helping take care of them after anesthesia has worn off, important that we know what to expect, how should pt be after waking up, what do we need to watch/concern about, what are they at risk for General Anesthesia Local Anesthesia Monitored Anesthesia Care (MAC) Regional Anesthesia Other forms of anesthesia: controlled hypotension, hypothermia, cry-anesthesia, acupuncture
Colorectal Screening
Every year between age 50 and 75 for high-sensitivity fecal occult blood testing, or flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years. depending on test is every 3-5 years. 76-85 decision made on an individual basis, look at comorbidity that the pt has as well as if it's a safe procedure for the pt to have especially for colonoscopy consider if safe for them to be under anesthesia, also consider if able to withstand other treatment if something else were found with that treatment Consult with the provider if screen should continue
A home health nurse is planning care for a patient who has Type 2 Diabetes Mellitus. Which of the following interventions should the nurse include to address primary prevention for this pt.
Instruct the patient to eat fatty fish twice weekly to prevent cardiovascular disease. Trying to PREVENT new illness, all others are tertiary because they already have DM and are trying to control it.
Pain and Discomfort after Surgery
Postoperative Traumatization of skin and tissues Reflex muscle spasms Anxiety/fear increase muscle tone and spasm
Possible fears
Fears: · Death · Pain · Anesthesia- that they have too much or too little · Mutilation- what the scar will look like, how will it be · Disruption of life- can't take time off **Ask pt. if previous surgery if haven't they don't know what to relate it with, fear is real, think about perception and understanding, knowledge level, what do older people do that have a hearing deficit- shake the head yes when they don't understand, ask them to tell you what they understand of what will happen today, if anxious or nervous info goes over them, sometimes have a follow up call because they forget or are too nervous to ask**
Assessment for Alterations in Temperature
Frequent temperature assessment Observe for early signs of inflammation and infection
Health Promotion Models
Health Promotion Model, Trans Theoretical Model (the stages of behavior change), Health Belief Model
Potential Alterations in Temperature
Hyperthermia Mild elevation first 48 hrs. (up to 100.4° F) may result from stress response Moderate elevation first 48 hrs. (>100.4° F) usually caused by respiratory congestion or atelectasis After 48 hrs. >100.0 usually infection
Endocrine System
If diabetic will watch blood glucose levels, are they on insulin, Type 1 or 2 if diabetic
Diagnosis for Alterations in Urinary Function
Impaired urinary elimination Potential complication: acute urinary retention
Potential Alterations in Integumentary System
Incidence of wound sepsis is higher in malnourished, immunosuppressed, older, or those with prolonged hospital stays or a lengthy procedure Post-op wound infection: Not evident until 3-5 POD or longer S/S wound infection Fluid around wound may impair healing
Interventions for Pain and Discomfort
Incisional splinting, etc. Position changes Aromatherapy Ambulation
Nursing Diagnosis for Alterations in Respiratory Function
Ineffective airway clearance Ineffective breathing pattern Impaired gas exchange Risk for aspiration Potential complication: Hypoxemia Potential complication: Pneumonia Potential complication: Atelectasis Potential Alterations in Circulatory Function ND is nothing more than a nursing problem
Surgeon
Preforms the procedure and overall responsible for procedure, responsible for medical hx, physical assessment, pt. safety
Age
Many diseases that age is going to put someone at higher risk for, look at age when thinking about early detection or prevention of diseases, some screenings are based on age
Who can sign a consent form if the patient is unable?
Medical emergency overrules needing a signature Parent can sign for a child POA
Adult Learners
Models to promote health in health promotion areas
Individual Focused Health Promotion Models
Most health promotion models that focus on individuals share these common themes: Cognition, Decision Making, Motivation, Behavior, Environment Cognition-change the thinking of the individual about a topic, what went into the thought and how to change the thought Decision making- Motivation-more under pt. education, what motivates the pt and make them want to change Behavior- what actually doing the behavior that will help promote their health Environment- what is around them that is changing this, or barriers in environment that stops them from making the healthy change
Difference Between Learning and Teaching
Most nurses and educators use both teaching and learning- combo Teaching should involve the pt. caregiver and RN Important task of RN and cannot be delegated-education done, LPN cannot teach
Potential Alterations in GI function
N/V, Abdominal distention
Fluid and Electrolyte Status
NPO (nothing by mouth) before surgery, shortened time of NPO now used to be 12 nothing after midnight hours now 4-5, keep hydrated Depending on age some may have more lab work than others,
Diagnosis for Alterations in GI function
Nausea Imbalanced nutrition: less than body requirements Potential complication: paralytic ileus Potential complication: hiccups
Post Op Wound Infections
Not evident until 3-5 days post-op or longer Signs and symptoms of wound infection- pus, drainage, redness , hot to touch, fever and chills, foul smell coming from the wound Fluid around wound may impair healing
Circulating Nurse
Not scrubbed in but are gowned, gloved and step back from environment by pt. work in less sterile environment, recorder and documentation, helps identify issues or problems, works in unsterile areas, coordinates team efforts
Assessment for Pain and Discomfort
Observe for nonverbal clues, pain scale
Operating Room
Operating room- controlled environment to minimize spread of pathogens, special airflow, · Filters · Controlled airflow · Positive air pressure-in the rooms prevent air from entering the OR from the halls and corridors · UV lighting- may be used, as UV radiation reduces the number of microorganisms in the air · No dust-collecting surfaces- has to be disposable like blue drapes, such as open shelves and tables are omitted · Materials resistant to corroding- don't rust and are resistant to sterilization, materials resistant t the corroding effects of strong disinfectants are used · Have cameras-if doing a procedure like laparoscopic or biopsy
Health Screenings
Optimization of Health- 3 main reasons they recommend health screenings Evidence based
Obesity in relation to surgery
Over 2/3 of US adults are overweight or obese (BMI > 25) 1/3 of adults age 20 and above are obese (BMI > 30) Children-estimated 16.9% of children and adolescents aged 2-19 years are obese Stresses cardiac and pulmonary systems Can predict who will have tougher airway Nutritional status R/T surgery Obesity -Stresses cardiac and pulmonary systems Predisposes to wound dehiscence and infection Slows recovery Adipose tissue absorbs and stores anesthesia
Preop Teaching
Patient has right to know what to expect and how to participate The Joint Commission (TJC) requires a H & P on chart, legal responsibility · Patient has right to know what to expect and how to participate o Increases patient satisfaction o Reduces fear, anxiety, stress, pain, vomiting
Surgical Team
Perioperative Nurse, Circulating Nurse, Scrub nurse, LPN or Surgical Tech, Surgeon, Surgeon's assistant, Registered Nurse First Assistant, Anesthesia Care provider
Planning for Discharge and Follow -up Care
Planning for discharge begins in preoperative period Information to both patient and caregivers
Diagnosis for Alterations in Temperature
Risk for imbalanced body temperature Hyperthermia Hypothermia
Diagnosis for Alterations in Integumentary System
Risk for infection Potential complication: Impaired would healing
Process of Patient Teaching- Planning
Set goals and priorities, select teaching strategies based on 3 factors: try to use different strategies together: Patient Characteristics, Subject Matter, Available Resources
Examples of Regional Anesthesia
Spinal Anesthesia, Epidural Block, -Spinal and Epidural are different but have similar effects in the body
Injury for Health Promotion for Children
Suffocation Aspiration-beans in nose, hot dogs, peanut butter, children put everything in mouths and parents don't think about it until too late, so educate early Falls Car seat safety- fire departments will do car seat safety drives, if gotten into accident that the seat is correct, want to make sure parents are aware of that Drowning- usually think about in the summer or before summer and educate on water safety with children Burns Accidental poisoning Farm injuries Bicycle safety-school age
Legal Preparation
TJC requires this · Each institution will have its own informed consent form · Must include adequate disclosure of diagnosis, treatment, risks, and probability of success · Surgeon responsible for obtaining consent · Nurse may obtain and witness signature · Verify patient has understanding · Permission may be withdrawn at any time
General Anesthesia
Technique of choice for patients · Loss of sensation with loss of consciousness · Skeletal muscle relaxation · Analgesia-
Difference Between Learning and Teaching: Learning
o May occur without teaching- may pick up on things but if RN can teach it can help reiterate the importance o Learning may result in observable change or the potential to change o Acquiring knowledge or skill o Can result in a permanent change in a person
TIVA-GA
Total IV anesthesia Inhalation, choice for long surgeries
RN first asssitant
assists RN
GI
hx of constipation, GI motility concerns
Nutrition for Children Health Promotion
infancy-breast feeding, or formula- ask how much they are consuming and making sure parents are giving formula to them properly Solid foods not before 4-6 months-some studies show if given earlier may promote obesity- education on starting foods earlier Good habits start early! Adolescents-eating disorders, obesity, STDs, and screening for suicidal ideation
Review of systems: Cardiovascular function
know if Hx of HTN, MI, CHF, heart attack, etc
Healthy People 2020 "overarching" goals
o 1. Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. o 2. Achieve health equality, eliminate disparities, and improve the health of all groups. o 3. Create social and physical environments that promote good health for all. o 4. Promote quality of life, healthy development, and healthy behaviors across all life stages. o From these goals it drives research and what kind of programs are put in place to promote health in the USA, good program for getting more evaluation and data collection for health disparities and figure out how they can help, helps to strengthen help policy and improve health process in the USA, these give goals on how well they are at educating/promoting for people in the USA to stay healthy
· The school nurse decided to check for scoliosis among the school's students. Such an intervention is:
o 1. Primary Prevention o 2. Secondary Prevention** o 3. Tertiary Prevention Secondary prevention- screening- finding it early Primary- make sure to do what you're supposed to do, tertiary- DM make sure to control BS to prevent further complication
· The school nurse decides to invite a nutritionist to discuss healthy lifestyles, such as eating vegetables and fruits for snacks. Such an intervention would be:
o 1. Primary prevention because we are preventing a disease such as obesity o 2. Secondary prevention 3. Tertiary prevention
Primary Prevention
o Addressing the needs of healthy clients, looking at promoting health and preventing disease o Examples- immunization programs, educating about child car seats, nutrition and fitness activities, general health education at schools
Difference Between Learning and Teaching: Teaching
o An interactive and dynamic process that involves a change in a patient's knowledge, behavior, and/or attitude in order to maintain or improve health o May be spontaneous, or it might be scheduled,
Anesthesia Care Provider
o Anesthesiologist-MD are a doctor that have gone to med school and have specialized in anesthesiology o Nurse anesthetist- is within their scope of practice to practice independently (like can do preop, write orders, wake them up, on call for traumas, airway management, induction of anesthesia, administer, watch during surgery, etc.
Live Vaccines
o Are 3 vaccines that we don't give to immunocompromised pt. o MMR, Varicella, Rotavirus
Caregivers
o Are important o About 1 in 4 adults provides care to someone on a daily basis. § Older adult women are the most common, but not the only family caregivers § Needs of the caregiver are vital in the teaching- learning interaction § Promoting pt. selfcare after discharge by teaching caregiver § Know the role of the caregiver § Usually family/significant others promoting possible financial, spiritual, emotional physical support § Some caregivers might be paid and not related § What is the health problem we want to talk about and what is the roleis? Make sure to give specific teaching and learning
Some Interventions that may be considered both primary prevention AND tertiary prevention
o Education o Immunizations o Screening- that we think of being secondary could be either like preventing pressure ulcer after spinal cord injury, its primary because preventing new condition however tertiary because preventing a comorbidity after injury o Nutritional health o Physical activity o Pharmacologic agents for smoking cessation and weight loss
Motivation
o Example: idea, emotion or physical need that causes a pt to act in a particular way
Secondary Prevention (screening)
o Identifying illness, providing treatment, and conducting activities that help prevent a worsening health status o Decreases morbidity and mortality o Ex: early screening, catching disease at early stage, early detection of DM, exercise programs for elderly that are frail so they don't have effects like broken bones
Teaching Learning Process: Challenges to teaching patients and caregivers
o Lack of time- #1 challenge- set learning priorities with pt, and make sure to talk to them, good idea how long you intend to be there with pt. and tell them that, helps both the pt and RN to make sure to organize info and focus on Infor for length of time, make sure to reinforce info as you go, o Personal feelings as a teacher- may be RN insecurity, happens when start as new RN, may have inner conflict/treatments that are being prescribed, sometimes RN have issue with discharge timeline, don't agree pt. should go home, o Early discharge from the health care system- the length of stay in hospitals is decreasing a lot, so less time to get the education in as they are there
Many Factors Influence Ability and Readiness to Learn
· .- how ready is the caregiver? · Physical needs being met? The teachings cant be planned around how ready the caregiver is, if pt is in pain they wont focus on teaching session, fatigue is an issue, try to plan around fatigue, think about the meds they are receiving- if they receive a sedative try to do teaching before they receive it · Mild stress or anxiety is good to increase attention- if pt is so stress or anxious it wont help, · Environment- make sure the environment is correct for teaching, can ask the pt. to prepare for education, don't talk over child or tv, make sure its ok · Adapt and modify expectations and strategies based on individual and caregiver learning needs-if pt. and caregiver are already educated about this don't need to spend as much time teaching, adapt the teaching based on what they already know · What does the patient already know?
Optimization of Health
· 3 main reasons they recommend health screenings: o Maintain high-level wellness o Prevent illness o Early detection and management of disease- important to do early screening for DM, easy test to run adding glucose to their fasting labs or taking a finger stick in clinic, easy way to screen for disease early,
Care of Postoperative Patient on Clinical Unit
· Airway is first · VS first, assessment · Initiation of post-operative orders, check wounds, do head to toe check, circulation, etc. · Early ambulation- the faster the pt moves the better the outcome, like change position, breathing deeply, turning on side, the more the pt stays and lays on bed the more it affect the outcome
Process of Patient Teaching: Assessment of learning involves:
· Assessment of learning needs involves 4 main areas: taking pt. into consideration · Physical characteristics- like hearing loss, vision issues, mobility issues- plan with PT · Psychologic characteristics- like anxiety and stress, prepared for education, mild can help but not extreme · Sociocultural characteristics · Learner characteristics o Age-how would you teach a preschooler?
Local Anesthesia Produces:
· Autonomic nervous system blockade · Skeletal muscle paralysis in area of affected nerve · Rapid recovery
Discharge Teaching
· Begins the moment a patient is admitted to a health care facility. · Inter disciplinary · Referrals-as inpatient or when discharged · Provide adequate information to referral · Most important education they will do because its when theyre leaving hospital and limits readmission · Important to have a good setting, include caregivers to make sure pt. follow discharge teaching when they go,
Preop Medication-
· Benzodiazepines- used for sedative effect and help relax the patient, most of them have an amnesia affect so when the procedure is done, and med wears off the patient forget some of what happened · Anticholinergics- used to help reduce secretions in mouth, especially if putting tube in mouth · Opioids- reduce pain, using less opioids now · Antiemetics- decrease nausea and vomiting, · Antibiotics- can also use ahead of time, IV 1 time before surgery suit propholactaly · BP medications- if HTN pt. they don't hold meds they give the meds, if diabetics don't hold insulin, if on oral diabetic med they will give that, this is a change in practice used to hold meds, strict NPO · Insulin · Eye drops- some eye drops cant be held, if eye procedure might be necessary to give meds
Inhalation Agents
· Breathe in and put mask over face, is type of gas, given with o2 o Enter body through alveoli o Rapid excretion by ventilation- when pt. wakes up they breathe deeply and rapidly excrete for body § Example - inhaled gas § Gasses- may be liquids to administer are put though a vaporizer along with o2 § Inhaled gases are probably the most widely used is also type of GA (general anesthesia
Immunizations
· CDC provides immunization schedules-recommended and catch-up vaccinations as well as recommendations for at risk patients, immunizations include for age based and those that need a catch up schedule: ex of catch up is if the parent decided child would not receive the immunizations and then they get to school age and they decide that they want them to receive them would need catch up schedule to get the vaccines they would've gotten earlier in life -Live Vaccines, Vaccine Contraindications, Vaccine Information Statements (VIS)
Surgeon's Assistant
· Can be physician or RN who functions in assisting role, can have a first assist or second assist have (PA, NP)
What is health literacy?
· Capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions · Basic literacy limitations can lead to health illiteracy. · Make sure they understand and can apply it to their life- if they cant apply its not helpful
Subject Matter
· Certain subject matter needs to be talked about and give written info to refer back, BP teaching requires teach back method
Affective
· Changing or influencing attitudes- like working with teen pop, need to change their attitude about situation before teaching them about it- like tanning beds, change how they feel
Other forms of controlled anesthesia
· Controlled hypotension · Hypothermia · Cryoanesthesia · Acupuncture
Scrub Nurse
· Designated to be the second set of hands, is gowned and gloved, sterile attire, right up next to pt. remain in sterile field, help give instruments, help, hold and support, works in sterile field
Health Hx (preop)
· Diagnosed medical conditions · Previous surgeries and problems · Menstrual/obstetric history · Familial diseases/Conditions · Reactions/problems to anesthesia (patient or family) -Allergies (drug and non-drug) - Tape allergy Latex allergy
Surgery Performed for:
· Diagnosis-biopsy, scope, like colon clean, obstruction of bronchi, etc. · Cure- repair of ACL, tear, ligament, appendectomy, etc. · Palliation- cutting nerve root, like with back, neck pain, or resecting a section inflamed like ulcerative colitis pt. · Prevention- potential mastectomy like being positive for BRCA gene and having breast tissue, removed, · Exploration- colonoscopy and remove polyp right them and there · Cosmetic improvement- plastic surgery for looks or for cancerous reasons, scar revision, burns- medically necessary vs not
Monitored Anesthesia Care (MAC)
· Drug induced depression of consciousness · Maintains own airway- doesn't need to be intubated · Analgesia, relieves anxiety and/or amnesia o Ex benzodiazepine, opioid o With MAC- important that even if pt. doesn't have artificial airway, RN have to monitor vitals, including respiratory rate, depth, and difficulty- are they working hard to breathe o Used a lot with different diagnostic test, like biopsy, or therapeutics, with med needing to be installed in spinal column o Nurses role is centered closely in watching the effects and monitoring the pt. closely
Environment
· Environment can be at home or where you work like having bad water quality at the house, work with lots of pesticides or an area with high air pollution at work
Day of Surgery preparation
· Final preop teaching- orientation, last teaching · Assessment · Communication of pertinent findings- pick up the phone call them, if they didn't mark the site, make sure labs have been done if needed and that results are in chart, look at them and interpret them make sure they're not abnormal, · Verify signed consent · Preoperative checklist (History and physical exam Baseline vitals- make sure they're normal Consultation records- ex: cardio consult make sure it's done before Nurse's notes Marking of surgical site- make sure it's done before)
Screening Recommendations
· Frequency of some major examinations and screenings are baseline for clients who are asymptomatic and do not have risk factors: Colorectal Screening, Childhood obesity, adult hearing loss, cervical cancer screening
Evaluation of Teaching
· Has the patient achieved learning goals? How do we evaluate? · Evaluation strategies: · Observe the pt. (show- back) helpful for skills · Observe verbal and nonverbal cues- if nodding yes and have a look of confusion on face · Discussion with pt./caregiver (teach-back) know that teach back is helpful, hearing the info twice · Pt's own evaluation of teaching- take what they say and ask if they understand Follow up after discharge- do because of how many readmissions, ask if they have questions or if they understood the teaching, pt. don't understand what they don't know until they get home, Assumptions of pt. knowledge can be dangerous- don't assume they understand everything about med even if taking them for years Evaluate, follow up, tell the pt. that there will be a follow up-ex, it's helpful because they can write down any questions, document all the teaching that is done, if not documented cant proof that it was done
Your role in preop
· Have knowledge of the nature of the disorder requiring surgery · Identify the individual patient's response to the stress of surgery · Have knowledge of the result of preoperative diagnostic tests · Identify potential risks and complications associated with surgery- ex: know there is research that the longer the bone that is fractured the greater risk for blood clot- pt with ankle fracture vs. femur, immobility, age, etc. increases risk factor · Patient interview- need good communication skills, how to relate o Wrong procedure is called never events, hospitals are required to have doctors have a preop chat and mark and initial surgical site and if they don't they are not allowed to start procedure
Health Promotion
· Health promotion is the process of enabling people to increase control over and to improve their health. (World Health Organization) · Essential things we do as nurses- promoting health and keeping people from getting sick is just as important as treating them when they have an illness
Implementation
· Include most important information at beginning of teaching session · Planned teaching strategies · Guide patient and caregiver information. Make sure to give most important info at beginning of session, · Teach new skills= don't just talk but can show them, use variety of teaching strategies · Teaching strategies can include any combination of o discussion - (the most common) --- Teach Back- EBP o lecture-discussion o demonstration-return demonstration o role play o a variety of learning materials (e.g., print, CDs/DVDs, computer-based programs) o peer teaching - (found in support groups). · Guide patients to use reliable internet information
Scope of Concepet
· Individual · Family · Community- like flu shot, · Population- like flu shot, · Environment- like hormones in food education or air pollution education
Surgical Suite
· Infection control- sterile environment, smooth surfaces that can be wiped, and floors, special lighting, carts with different equipment, suite is a contained sterile enclosed environment, staff cant go in and out unless it's a circulating nurse, but not the nurse assisting with surgical procedure, they have a anesthesia cart-for CRNA and has supplies, have rolling cart with wheels, · Temperature controlled · Equipment checked for electrical safety · Patient privacy
Malignant Hyperthermia
· Inherited is rare and life-threatening event and can be triggered by certain drugs used for anesthesia · Hypermetabolism of skeletal muscle resulting in altered control of intracellular calcium o Clinical manifestations- Tachycardiac, tachypnea, hypercarbia, ventricular arrhythmias, rise in body temp NOT an early sign, can result in cardiac arrest and death, name is misleading because a rise in temp is not an early sign,
Epidural Block
· Injection of agent into epidural space · Does not enter CSF · Binds to nerve roots as they enter and exit the spinal cord · Patient can remain fully conscious- is the kind of anesthesia that is used during labor for pain control, used commonly for procedures to lower extremities, · Less chance of spinal HA as not in spinal canal CSF · Medication used for epidural is a member of the caine family like lidocaine, mepivacaine, etc. · Nurses role during epidural- when pt. has an epidural they will inject and insert that and then attach it to a handheld infusion pump that lays in bed with them, RN job to watch pt. monitor for side effects like itching, watch site for oozing, bleeding, infection, sometimes the Caine family meds used cause urinary retention, pt will prob have o2 on while epidural is being infused, frequent vitals, check for sedation, check for pain control, at risk for developing a hematoma at the site, watch and monitor during and afterwards · Pt can also lay on side and lay in knee chest position to open the spinous processes and helps for easier insertion of medication
Spinal Anesthesia
· Injection of anesthetic agent into cerebral spinal fluid (CSF) of subarachnoid space · Usually below L2 · Provides autonomic, sensory, and motor blockade of pain receptors · Important as nurses that when pt. has this, they can become hypotensive from the vasodilation that occurs, important that they monitor for that and anticipate as a possibility with spinal anesthesia, · Pt. can experience a spinal headache after having it, monitor for site after injecting anesthesia because can leak CSF, blood, can become infected from site, check vitals every 15 minutes initially and then every hour and then every 4 hours, use a little bit of Benadryl before anesthetic agent because Benadryl is an antihistamine and decreases the pt. to having any kind of allergic reaction to the anesthesia, usually pt. will have o2 when getting the injection, once they are stable and no side effects the o2 can be removed, assess during the initiation of spinal anesthesia and afterwards · Pt can sit up and get in knee chest position and roll shoulders forward that helps open the spiney processes in the back so the provider can find the landmarks easier and opens up space to inject the anesthesia
Psychomotor
· Integrating knowledge and ability to perform a skill- like taking own BP (ex. Doing a dressing change and showing them how to do a dressing change and then teaching them about watching for signs of infection)
Role of Patient and Caregiver Teaching
· Interactive and dynamic process · Challenging and rewarding nursing role · General goals for patient teaching include o Health promotion- teaching- ex surgical pt. and reviewing sigs of infection and review, understand disease info and make sure they can take care of themselves o Disease prevention- healthy diet and exercise, early screenings- vaccines to prevent disease before it starts o Illness management- how to manage comorbidities- have the disease already and how to manage the illness to get them to optimal health like DM how to manage, HTN- set with home bp cuff to check, med info given to them- pt. more compliant taking med if they understand why they are taking it, 70% of deaths in the US are due to chronic illness o Selection and use of appropriate treatment options- pt. can't make right decisions for themselves if they cant understand what the options are o Overall goal is to keep pt. healthy and keep out of hospital/clinic and living their optimal level of health
Lifestyle Behaviors
· Isn't just diet and exercise but includes stress, substance use, sun exposure, etc.
Patient Characteristics
· Know this by talking to them, just because they talk about something in educated manner doesn't mean they know everything, high education is important but might not be applicable o Age, educational background, culture, language skills, and nature of illness
Local Anesthesia
· Loss of sensation without loss of consciousness can be applied: o Topically- EMLA cream for IV starts o Subcutaneously- inject into surrounding tissue- ex: hernia repair § Ex of local: EMLA cream, Lidocaine, novacaine, others can be given with nebulizer or injected subq, injectables, ophthalmic § They provide local anesthesia and might do prior of doing sutures for lacerations or stitiching something up
Nursing focus for postop
· Maintain patient safety- maintain the airway · Identify actual and potential patient problems- pain, confused- causes fear or anxiety, bleeding, infection, circulation can be affected if breathing too fast from ex of anxiety or slow from ex of pain, practice breathing with them because they can fall asleep and breath shallow and affects circulation
Genetics
· Many diseases are genetic, role of RN is to do a thorough health hx and make sure its up to date, heart disease, mental health, cancers are hereditary, need to know and have in chart of family hx to improve screening process
Important to Include in Discharge Teaching
· Medications- try to focus during the stay, give them written info to refer back · Equipment- do they need any, like raiser, walker, how are they getting it, · Diet- should've been taught along the way- · Activity- what are the restrictions, and how long · Disease Process- include info, shouldn't be the first time they are hearing, should be along the way · Referrals- Rehab or to outpt, PT, OT, where do they need to check in afterwards · Pt/Family responsibilities- does the family have to do everything or did RN do the scheduling or meds scheduling · When to notify physician · Return appointments- may be scheduled for patient before d/c- understand what appt. need to happen and if they are already set up for them · Cans- temp over 100, skin looks red, any side effects- when to notify, usually highlight · Learner characteristics- make sure you know about them and how they learn, connect with them
IV induction agents
· Meds that given to pt. IV o Induce pleasant sleep o Rapid onset § Example - Versed (amnesiac)- induces pleasant rest/sleep, has amnesia affect, 99.9% of time after procedure they wake up and have no memory of what happened besides being rolled in, and waking up · Can use IV induction or short acting gas (children to start IV)
Interventions for Alterations in Urinary Function
· Monitor o Are they NPO, do they have an IV in they should produce urine, ask when they last voided if PACU nurse didn't say, what meds they have incase meds suppress/ decreased urine production, get up early, for early ambulation o Sometimes if laying flat don't feel like voiding, but if stand they might have too o Bladder scanner can help see if they have urine in bladder
Interventions for Alterations in Circulatory Function
· Monitor VS- especially P and B/P · Skin color, temp, moisture · B/P, P, Arrythmias · Monitor fluids, I & O even if NPO hydrate with IV fluids · Monitor chronic disease states · Monitor cardiac rhythm · Out of bed slowly
Interventions to Prevent Deep Vein Thrombosis (DVT) stasis of blood
· OOB to chair early and often · While on bed rest: Dorsiflex, change position frequently, rotate ankles · TED hose- don't do much to stop clots as much as intermittent compression socks but help decrease swelling · Intermittent Compression boots- they compress and relax
Both spinal and epidural anesthesia
· Observe closely for signs of autonomic nervous system (ANS) blockade · Bradycardia · Hypotension Nausea/vomiting
Perioperative Nurse
· RN that prepares the room with the team, is the pt advocate, do additional details, tasks that need to be completed, do last check that everything is documented and in chart like pre op lab, provides physical and emotional comfort for pt, does teaching before, maintains pt. safety, privacy, dignity and communicates with pt.
Regional Anesthesia
· Regional nerve block o Agent is injected into or around specific nerve or group of nerves o Ex: can do intercostal nerve block o Also used for chronic pain control, using a lot more nerve blocks § Ex: if pt. needs joint replacement, shoulder replacement, ankle, etc. they are putting them under MAC and installing a nerve block and the block stays in place for 24-48 hours, effectiveness maintained that long, pt. is awake and is with minimal pain so they can ambulate, total hip pt. can be up within hour after going back to post-surgical- ex § Need to know what procedure to monitor, § Ex: putting in nonvaccine or lidocaine- MAC before procedure which can cause discomfort of it going in like pressure, tightness, stinging, burning, but once the med is in the discomfort goes away Ex: spinal injection is between 3 and 4th vertebrae
Care in the PACU (Post Anesthesia Recovery Unit)
· Report given to PACU nurse- OR nurse gives report to PACU nurse in SBAR, · Priority care given to monitoring and management of respiratory and circulatory function, pain, temperature, and surgical site, care like if given antibiotics, or if something was done during surgery · Similar care on post-op unit
Common Post-operative complications
· Respiratory complications: o Atelectasis, Pneumonia, Airway obstruction · Circulatory complications o Hypovolemic Shock ,Fluid overload, Fluid depletion o Thrombophlebitis-DVT o Pulmonary embolus- blood clot in blood · Integumentary-Surgical site infection o Skin breakdown o Surgical site infection
Gender
· Sometimes we base our screenings strictly on gender we know that men are at higher risk of suicide and women are at higher risk for incidents of auto immune disorders, gender may guide our screening practices and help to get better aim for what we want to screen pt. for
Surgical Safety
· Time- Outs/ Pause for Cause · Surgical safety checklist doesn't apply just to preop but also intra op right before pt. is given anesthesia, · Make sure to have the correct patient, procedure, surgical site, Starts when the pt enters surgical suite-1sttime, surgical nurse 2ndtime responsibility of the circulating nurse, entire team prior to beginning
Assessment for Alterations in Integumentary System
· Type of wound, drains, and expected drainage · Usual drainage pattern · Sanguineous · Serosanguineous · Serous · Wound dehiscence- when wound breaks open, separation of wound edges · Wound evisceration- separation or protrusion of intestines out through the opening
Assessment for Alterations in Urinary Function
· Urine · Assess urinary catheters · Adequate urine output If no catheter, patient should be able to void
Potential Alterations in Circulatory Function Assessment
· VS - pulse and B/P · Color - temp, moisture, looking for cyanosis, looking at extremities · B/P parameters - usually notify MD if B/P is <90 or 160 systolic · Pulse parameters - usually notify MD if pulse if <60 or >120 · Arrythmias- have them initially on a heart monitor and notify if there are any irregularities
Interventions to Alterations in Respiratory Function
· Vital signs/oxygen sat, if o2 is low might need to wake them up, etc. · Deep. Breathing/coughing · Incentive spirometry- forces them to expand airway most of the time they cough which helps move secretions, open airway, etc. · Turning in bed, ambulation · Oxygen therapy- · Splinting incision- if procedure in mid-section or chest they don't move as much if they take a pillow and support as they are moving, counterpressure helps with pain control and helps them move better · Hydration, avoid positioning that decreases ventilation, hydrate via oral or IV · Monitor response to narcotics- narcotics suppress respiratory drive doesn't help the pt breathe deeply because they don't, benefits pt. resp status that they don't use narcotics as much · What other things can be done to control the pain,
Cognitive
· increased knowledge- useful when talking about meds, make sure they are compliant when they leave
Physiological Factors
· like high BMI at risk for DM, if pregnant at higher risk for preeclampsia
Health Literacy
· not just the ability to read info, but understand how it applies to health, if don't understand they wont be able to do things to stay healthy, like options of pt with cancer, understand cancer and what are the options like surgery, chemo, both, how will it affect as a person, recommend a level of 5th grade level when its written information, is the writing big enough, · How does the pt. like to learn · Three areas of learning · Which domain do we want to focus on?
What is General Anesthesia used for
· quick onset · good for anxious pt. · can be used for long period of time · good when the other options are contraindicated if pt. has procedure that takes a long time, good when not good candidate for epidural, regional anesthetic, block o Refuse or contraindications for regional
LPN or Surgical Tech
· responsible for handing instruments, scope of practice is limited than RN
Available Resources
· some hospitals have info that you can print out and its been put together for pt. o Support groups o Teaching programs online- used a lot especially now o Online sites- can look at to know about diseases o Make sure to know what is available o Discussion, lecture, both, return demonstration- you show them and they show you, role play- peds pop or clinic, variety of learning materials- like the written stuff, with some procedures they will give them a DVD to learn about it, pure teaching- mostly in support groups can be helpful for adults and peds
Professional in that environment have..?
· surgical gowns, sterile gloves, mask, headcovers, face shields, now can have a hood over the head,
Learner Characteristics
· use multiple formats, visual aids are helpful, review all material that's important and make sure its at right level, make sure pt. knows where to find info, ex- web MD not always helpful, or mayo clinic is more reliable has info for pt., using a combination of strategies and review info before giving to pt. peer teaching in support groups for pt. with eating disorders- ex. Helpful with peds and adults
