Nursing Skills exam 3
Before surgery:
-adress anemia -discontinue anticoagulants and anti platelets
immediate care
-assessment (resp., card.(vitals), CNS (response and stimuli), fluid status, wound status, pain, general condition)
malnourishment risk factors
-fluid and electro imbalances -slow wound healing -infection
kidney and liver risk during surgeries
-fluids and electrolyte imbalances -metabolism and excretion of drugs -wound healing
heart diseases risk during surgeries
-hemorrhage -hypovolemic shock -hypotension -thromboplebitis
Post operative care
-immediate -ongoing care
Wound complications
-infection -hemorrhage -dehiscence(wound separates) and evisceration(protrusion) -fistula formation
ongoing care
-promote health, teach care for when pt goes home
respitatory depression risk during surgeries
-resp depression -post-op pneumonia
obesity risk factors
-resp, card, and positional & GI problems
NG tube
-short term use less than 4 weeks
pts at risk
-smokers, obese -malnourished, anticoagulant users -infected wounds, cough, vomit
lymphocyte normal range
1,500-4,000
Albunim normal range
3.4-5.4
Glucose normal range
70-110 mg/dL
Fat soluble vitamins
A, D, E, K
water soluble vitamins
B and C
moderate sedation/analgesia
Conscious sedation or procedural sedation. Used for short term and minimally invasive procedures.
factors affecting wound healing
Dessication- dehydration Maceration- overhydration Necrosis- death of tissue Biofilm- a thick grouping of microorganisms
wound stage 4
Full-thickness tissue loss with exposed bone, muscle, or tendon
ICOUGH for atelectasis
I - Incentive Spirometry. C - Coughing & deep breathing. O - Oral care (brush teeth and use mouthwash 2x a day). U - Understanding (pt and staff education). G - Getting out of bed at least 3x a day. H - HOB elevation.
Stages of Anesthesia
I: Induction; the period between administration of anesthesia and loss of conciousness II: maintenance: that point until end of procedure III: Emergence: pt wakes and ready to leave OR
major surgery
Involves extensive reconstruction or alteration in body parts; poses great risks to well being
Norton Scale
Physical and mental condition, activity, mobility, and continence
minor surgery
Procedure without significant risk; often done with local anesthesia, lesions and deformities
Cold therapy
Promotes vasoconstriction, increases blood viscosity, decreases metabolism of tissues, has local anesthetic effect - Decreases muscle tension - should not be applied for longer than 20 minutes or reflex vasodilation can occur -increases comfort
Heat therapy
Promotes vasodilation, decreases blood viscosity, increases metabolism of tissues, increases capillary permeability - should not be applied for longer than 20-30 minutes, or reflex vasoconstriction and tissue congestion can occur, accelerates inflammatory response
RYB
Red - protect Yellow - cleanse Black - debride
constructive
Restores function lost or reduced as result of congenital anomalies (cleft palate repair)
regional anesthesia
Temporary interruption of nerve conduction, is produced by injecting an anesthetic solution near the nerves to be blocked.
evisceration
The most serious complication of dehiscence. The wound completely separates, with protrusion of viscera through the incisional area.
ablative
To remove a diseased body part (amputation, appendectomy)
Intentional wounds are.....
Trauma that occurs during therapy such as venipuncture or tumor removal.
purulent drainage
WBC's, liquified dead tissue debris, dead and live bacteria (dark yellow, or green) [green=Pseudomonas aeruginosa]
eschar
a dry, dark scab or falling away of dead skin, typically caused by a burn, or by the bite of a mite, or as a result of anthrax infection.
unintentional wounds
accidental, occur from unexpected trauma (stabbing, gunshot)
Skin Assessment
acute:every shift long-term: admission and weekly for 4 weeks home: every visit
Waterlow Scale
age and gender (sex), build and weight, continence, skin type, mobility, nutrition, and special population-specific risks
basal metabolism
amount of energy required to carry out involuntary activities of the body at rest
Ischemia
an inadequate blood supply to an organ or part of the body, especially the heart muscles.
closed wound
an internal injury with no open pathway from the outside (falls, assault)
biofilm
antibiotic resistance
maturation
begins 3 wks after injury, scar is formed "remodeling stage"
decreased hematocrit risk factors
bleeding, anemia
hyper/hypovolemia risk factors
cardiac problems
adrenal steroids risk factors
cardiovascular collapse from abrupt withdrawal
atelectasis
collapsed lung; incomplete expansion of alveoli
serous drainage
composed of clear, serous portion of the blood and from serous membranes
hydrolyzed formula
composed of partially digested protein peptides and are referred to as free amino acids used for clients who have partially functioning GI tract or those who have an impaired ability to digest and absorb foods most provide 1.0-1.2 cal/mL High calorie formulas provide 1.5-2.0 cal/mL
diagnostic
confirm diagnosis (breast biopsy)
How to treat wounds:
cover wound with sterile towels moistened with sterile 0.9% sodium chloride and notify the provider -place in low fowler's position and cover abdominal contents -npo
"-ine" histamines
decrease gastric acidity & volume as well as oral secretions
Desiccation
dehydration crust forms over site and delays healing
trauma
delayed or inability to heal
Surgery based on purpose
diagnostic, curative, preventative, ablative, palliative, reconstructive, transplantation, constructive
pressure
disrupts blood supply and delays healing
chronic wound
do not progress through stages of healing; healing impeded (diabetes, injuries)
surgery based on urgency
elective, urgent, emergency
diuretics risk factors
electrolyte imbalances
wound stage 1
erythma and intact skin
Narcotic analgesics
facilitate sedation and relaxation
wound stage 3
full thickness tissue loss with visible fat
Anesthesia types
general, regional, local, conscious sedation
Wound complications: hemorrhage
hematomas form(clotted blood)
Phases of healing
hemostasis and degeneration, inflammation, proliferation and migration, remodeling and maturation
parenteral nutrition
hypertonic -formulas with all macros
endocrine risk during surgeries
hypoglycemia, acidosis -slow wound healing -post-op cardiovascular complications
Hemostasis
immediately after injury, blood clotting begins
edema
inadequate oxygen supply and nutrients
tranquilizers risk factor
inc. hypotensive effects
Regional Anesthesia: Spinal
injection into cerebrospinal fluid in subarachnoid space [lower abdominal, pelvic, hip, knee surgeries]
Regional Anesthesia: Epidural
injection into the epidural space [anorectal, vaginal, perineal, hip, lower extremity surgeries]
standard formula
intact proteins and contains balanced proportion of macronutrients
Wound Classification
intentional, unintentional, open, closed, acute, chronic
open wound
intentional/unintentional -portal of entry is open (incisions and abrasions)
peripheral pn
isotonic -dextrose and amino acids
inflammatory
lasts 2-3 days, WBC move to wound and attract fibroblasts that help fill up the wound -inc tempo and general malaise
Trendelenburg position
lying on back with body tilted so that the head is lower than the feet
lithotomy position
lying on back with legs raised and feet in stirrups
surgery based on degree of risk
major and minor
anticoagulant risk factors
may precipitate hemorrhage
what are vitamins needed for?
metabolism of carbs, protein, and fats
what environment is best for wound healing?
moist environment
slough
moist, stringy or mucinous, white/yellow tissue that tends to be loosely attached in clumps to the wound bed
overweight risk factors
obstructive sleep apnea -reduced resp fxn -GERD -infection
infection
occupies all energy and delays healing
fistula
often result from an infection that developed into abcess
maceration
overhydration, softening and breakdown of skin from prolonged exposure to moisture and changes in PH
wound complications: dehiscence & evisceration
partial or total separation of wound layers
wound stage 2
partial thickness skin loss or blister
preoperative phase
period of time from when the decision for surgical intervention is made to when the patient is transferred to the operating room table
postoperative phase
period of time that begins with the admission of the patient to the postanesthesia care unit and ends after follow-up evaluation in the clinical setting or home
intraoperative phase
period of time that begins with transfer of the patient to the operating room area and continues until the patient is admitted to the postanesthesia care unit
elevated nitrogen risk factors
potential kidney problems
the perioperative phases
preoperative, intraoperative, postoperative
Wound Complications: Infection
purulent drainage, pain, redness, swelling
"-pam" sedatives
reduce anxiety
proliferation
regenerative epithelial cells form across the wound, granulation tissue 24-48 hrs
palliative
relive or reduce intensity of illness but its not curative (colostomy)
antibiotics risk factors
respiratory paralisis
Braden Scale
sensory perception, moisture, activity, mobility, nutrition, friction and shear
urgent surgery
surgery that is not an emergency, but must be done within a reasonably short time frame to preserve health 24-48 hrs
elective surgery
surgery that is recommended but can be omitted or delayed without catastrophe
emergency surgery
surgery that must be performed immediately to save the person's life or a body organ
general anesthesia
the blockage of all body sensations, causing un-consciousness and loss of reflexes. -inhaled or IV
transplantation
to replace organs or structures that are diseased or malfunctioning (kidney,liver, or cornea)
topical and local anesthesia
used on mucous membranes, open skin, wounds, burns Sometimes used in conjunction with other types of anesthesia
acute wound
usually heal within days to weeks risk of infection is low
Risk of anesthesia
• Intubation • Atelectasis • Pleural fluid • Increased sputum production • Pleural effusion • Arrhythmias • pneumonia Halothane
