Podcast
Questions and Answers
Which of the following best describes the key difference between primary aging and secondary aging in older adults?
Which of the following best describes the key difference between primary aging and secondary aging in older adults?
- Primary aging is considered a normal, universal process, while secondary aging results from disease or environmental factors. (correct)
- Primary aging affects physical health, whereas secondary aging affects mental health.
- Primary aging is the result of environmental factors, while secondary aging is genetically determined.
- Primary aging occurs rapidly, while secondary aging is a gradual process.
An 86-year-old patient is admitted to the hospital. Based on the provided age subgroups, how would this patient be classified?
An 86-year-old patient is admitted to the hospital. Based on the provided age subgroups, how would this patient be classified?
- Young old
- Elite old
- Middle old
- Old old (Frail-elderly) (correct)
Why is the recommendation to 'start low and go slow' with medication dosages particularly important for older adults?
Why is the recommendation to 'start low and go slow' with medication dosages particularly important for older adults?
- Older adults frequently require higher doses of medication due to decreased absorption.
- Older adults often have decreased physiological reserves and are less able to tolerate standard medication doses. (correct)
- Older adults are more likely to be non-compliant with complex medication regimens.
- Older adults tend to metabolize medications more quickly than younger adults.
A nurse is using the Fulmer SPICES assessment tool. Which of the following findings would indicate a potential issue needing further evaluation?
A nurse is using the Fulmer SPICES assessment tool. Which of the following findings would indicate a potential issue needing further evaluation?
Which of the following is an example of secondary depression in an older adult?
Which of the following is an example of secondary depression in an older adult?
A patient is suspected of having delirium. Which assessment tool is most appropriate for initial evaluation?
A patient is suspected of having delirium. Which assessment tool is most appropriate for initial evaluation?
An older adult is found shivering in their apartment, which is set to 65°F (18.3°C). Which physiological response is the body attempting to initiate?
An older adult is found shivering in their apartment, which is set to 65°F (18.3°C). Which physiological response is the body attempting to initiate?
What is the primary concern regarding thermal regulation in older adults during periods of extreme heat?
What is the primary concern regarding thermal regulation in older adults during periods of extreme heat?
A patient reports pain that started without any apparent tissue damage or inflammation, and standard analgesics provide little relief. Which type of pain is the patient MOST likely experiencing?
A patient reports pain that started without any apparent tissue damage or inflammation, and standard analgesics provide little relief. Which type of pain is the patient MOST likely experiencing?
Which of the following BEST describes the transmission phase of nociception?
Which of the following BEST describes the transmission phase of nociception?
A patient is prescribed multimodal analgesia for post-operative pain. Which of the following medication combinations BEST represents this approach?
A patient is prescribed multimodal analgesia for post-operative pain. Which of the following medication combinations BEST represents this approach?
A patient with a history of renal insufficiency is prescribed a non-steroidal anti-inflammatory drug (NSAID) for pain. What potential adverse effect requires careful monitoring?
A patient with a history of renal insufficiency is prescribed a non-steroidal anti-inflammatory drug (NSAID) for pain. What potential adverse effect requires careful monitoring?
A patient is receiving intravenous morphine for severe pain management. What is the MOST important nursing intervention to prevent a potentially life-threatening adverse effect?
A patient is receiving intravenous morphine for severe pain management. What is the MOST important nursing intervention to prevent a potentially life-threatening adverse effect?
A patient taking an opioid agonist-antagonist reports increased pain and begins to exhibit signs of withdrawal. What is the MOST likely reason for this?
A patient taking an opioid agonist-antagonist reports increased pain and begins to exhibit signs of withdrawal. What is the MOST likely reason for this?
A patient is prescribed gabapentin as an adjuvant analgesic for chronic neuropathic pain. What is the mechanism of action of this medication?
A patient is prescribed gabapentin as an adjuvant analgesic for chronic neuropathic pain. What is the mechanism of action of this medication?
A nurse is preparing to administer intravenous acetaminophen to a patient with a fever. Over what minimum time frame should the nurse administer the medication?
A nurse is preparing to administer intravenous acetaminophen to a patient with a fever. Over what minimum time frame should the nurse administer the medication?
While caring for a patient receiving opioid analgesics, the nurse observes that the patient is somnolent and snoring. What is the MOST appropriate initial nursing action?
While caring for a patient receiving opioid analgesics, the nurse observes that the patient is somnolent and snoring. What is the MOST appropriate initial nursing action?
A patient is being treated for hypertension. The patient is of African descent. Which of the following is Generally recommended as a first-line treatment option?
A patient is being treated for hypertension. The patient is of African descent. Which of the following is Generally recommended as a first-line treatment option?
A patient with hypertension is prescribed a thiazide diuretic. Which electrolyte imbalance is MOST likely to occur with this medication?
A patient with hypertension is prescribed a thiazide diuretic. Which electrolyte imbalance is MOST likely to occur with this medication?
A patient is prescribed a potassium-sparing diuretic. What important dietary instruction should the nurse provide?
A patient is prescribed a potassium-sparing diuretic. What important dietary instruction should the nurse provide?
A patient is started on an ACE inhibitor for hypertension. What common side effect should the nurse discuss with the patient?
A patient is started on an ACE inhibitor for hypertension. What common side effect should the nurse discuss with the patient?
A patient with angina takes nitroglycerin for chest pain but continues to experience pain after the first dose. Following protocol, what should the patient do NEXT?
A patient with angina takes nitroglycerin for chest pain but continues to experience pain after the first dose. Following protocol, what should the patient do NEXT?
A patient who has a history of cardiac disease reports that she is comfortable at rest but experiences fatigue, palpitations, and shortness of breath with moderate exertion. Based on the New York Heart Association (NYHA) Functional Classification, how would this patient be classified?
A patient who has a history of cardiac disease reports that she is comfortable at rest but experiences fatigue, palpitations, and shortness of breath with moderate exertion. Based on the New York Heart Association (NYHA) Functional Classification, how would this patient be classified?
Which medication class requires a washout period if a patient is currently taking an ACE inhibitor due to the risk of adverse reactions?
Which medication class requires a washout period if a patient is currently taking an ACE inhibitor due to the risk of adverse reactions?
A patient with heart failure is prescribed digoxin. Which assessment finding would warrant the closest monitoring by the nurse?
A patient with heart failure is prescribed digoxin. Which assessment finding would warrant the closest monitoring by the nurse?
Which assessment finding is most indicative of pulmonary edema?
Which assessment finding is most indicative of pulmonary edema?
A patient with atrial fibrillation is prescribed warfarin. What is the primary goal of this medication?
A patient with atrial fibrillation is prescribed warfarin. What is the primary goal of this medication?
A patient diagnosed with mitral stenosis may experience which of the following symptoms?
A patient diagnosed with mitral stenosis may experience which of the following symptoms?
A patient with aortic stenosis is being treated for A-fib. Which medication would require cautious administration?
A patient with aortic stenosis is being treated for A-fib. Which medication would require cautious administration?
An athlete diagnosed with hypertrophic cardiomyopathy is at increased risk for what condition?
An athlete diagnosed with hypertrophic cardiomyopathy is at increased risk for what condition?
A patient with infective endocarditis should be assessed for signs of arterial embolization. Fragmentation of vegetative lesions may cause which of the following?
A patient with infective endocarditis should be assessed for signs of arterial embolization. Fragmentation of vegetative lesions may cause which of the following?
Which assessment finding is most indicative of cardiac tamponade?
Which assessment finding is most indicative of cardiac tamponade?
A patient with suspected rheumatic carditis should be assessed for a recent history of which type of infection?
A patient with suspected rheumatic carditis should be assessed for a recent history of which type of infection?
A patient with peripheral artery disease (PAD) reports experiencing leg pain that occurs with exercise and is relieved by rest. How would this be classified?
A patient with peripheral artery disease (PAD) reports experiencing leg pain that occurs with exercise and is relieved by rest. How would this be classified?
A patient with severe peripheral arterial disease (PAD) has ulcers on their toes. Which stage does this represent?
A patient with severe peripheral arterial disease (PAD) has ulcers on their toes. Which stage does this represent?
Which intervention is most important to teach a patient with venous insufficiency?
Which intervention is most important to teach a patient with venous insufficiency?
A patient with varicose veins is considering treatment options. Which of the following is a non-surgical intervention for this condition?
A patient with varicose veins is considering treatment options. Which of the following is a non-surgical intervention for this condition?
What finding would cause the most concern in a patient prescribed SGLT2i agents?
What finding would cause the most concern in a patient prescribed SGLT2i agents?
An elderly patient is admitted with suspected hypothermia. Besides core body temperature, which assessment finding is MOST indicative of this condition?
An elderly patient is admitted with suspected hypothermia. Besides core body temperature, which assessment finding is MOST indicative of this condition?
A patient is prescribed a diuretic medication. What is the MOST important teaching point to prevent heat exhaustion?
A patient is prescribed a diuretic medication. What is the MOST important teaching point to prevent heat exhaustion?
During a heat wave, which intervention is MOST important for a home health nurse to implement for a socially isolated elderly patient living alone?
During a heat wave, which intervention is MOST important for a home health nurse to implement for a socially isolated elderly patient living alone?
A patient with a fever is shivering. How do you explain the physiological rationale.
A patient with a fever is shivering. How do you explain the physiological rationale.
Which nursing action BEST exemplifies Watson's Caritas Process of 'cultivating sensitivity to one's self and to others'?
Which nursing action BEST exemplifies Watson's Caritas Process of 'cultivating sensitivity to one's self and to others'?
A patient reports feeling short of breath. Using the Borg Scale, which nursing intervention is MOST appropriate?
A patient reports feeling short of breath. Using the Borg Scale, which nursing intervention is MOST appropriate?
A nurse is caring for a patient using Helen Erickson's Modeling and Role-Modeling theory. Which action BEST demonstrates the aim of 'promoting control' for the patient?
A nurse is caring for a patient using Helen Erickson's Modeling and Role-Modeling theory. Which action BEST demonstrates the aim of 'promoting control' for the patient?
A patient is experiencing pain. What is the MOST important principle to remember when assessing and managing the patient’s pain?
A patient is experiencing pain. What is the MOST important principle to remember when assessing and managing the patient’s pain?
According to Roy's Adaptation Model, a patient's anxiety about upcoming surgery would be considered which type of stimuli?
According to Roy's Adaptation Model, a patient's anxiety about upcoming surgery would be considered which type of stimuli?
A nurse overhears a colleague making disparaging remarks about a patient's cultural background. Which principle from the ANA Code of Ethics for Nurses is MOST directly violated?
A nurse overhears a colleague making disparaging remarks about a patient's cultural background. Which principle from the ANA Code of Ethics for Nurses is MOST directly violated?
During a surgical 'time out', which action is MOST critical for the circulating nurse to perform?
During a surgical 'time out', which action is MOST critical for the circulating nurse to perform?
The patient is scheduled for surgery. The pre-operative order states, 'Administer prophylactic antibiotic within one hour prior to surgical incision.' The surgery is scheduled for 0900, when should the nurse administer the antibiotic?
The patient is scheduled for surgery. The pre-operative order states, 'Administer prophylactic antibiotic within one hour prior to surgical incision.' The surgery is scheduled for 0900, when should the nurse administer the antibiotic?
A patient is scheduled for surgery and expresses concerns about receiving a blood transfusion due to religious beliefs. What is the MOST appropriate nursing action?
A patient is scheduled for surgery and expresses concerns about receiving a blood transfusion due to religious beliefs. What is the MOST appropriate nursing action?
Which of the following actions is MOST important for the nurse to implement to prevent respiratory complications in a post-operative patient?
Which of the following actions is MOST important for the nurse to implement to prevent respiratory complications in a post-operative patient?
A patient undergoing general anesthesia exhibits a sudden increase in body temperature, muscle rigidity, and tachycardia. Which complication is MOST likely occurring?
A patient undergoing general anesthesia exhibits a sudden increase in body temperature, muscle rigidity, and tachycardia. Which complication is MOST likely occurring?
A patient undergoing surgery suddenly develops jaw and upper chest muscle rigidity, along with unexpected tachycardia and increased end-tidal CO2. Which of the following conditions is MOST likely occurring?
A patient undergoing surgery suddenly develops jaw and upper chest muscle rigidity, along with unexpected tachycardia and increased end-tidal CO2. Which of the following conditions is MOST likely occurring?
A patient is suspected of having malignant hyperthermia. After discontinuing the triggering anesthetic agents, which of the following medications should be administered FIRST?
A patient is suspected of having malignant hyperthermia. After discontinuing the triggering anesthetic agents, which of the following medications should be administered FIRST?
A patient receiving moderate sedation for an outpatient endoscopy becomes unresponsive. Initial interventions should include which of the following?
A patient receiving moderate sedation for an outpatient endoscopy becomes unresponsive. Initial interventions should include which of the following?
Which of the following parameters is MOST important for a nurse to monitor in a patient undergoing moderate sedation?
Which of the following parameters is MOST important for a nurse to monitor in a patient undergoing moderate sedation?
A patient in the PACU has a blood pressure that is 25 mmHg higher than their pre-operative baseline. Which of the following is the MOST appropriate initial nursing action?
A patient in the PACU has a blood pressure that is 25 mmHg higher than their pre-operative baseline. Which of the following is the MOST appropriate initial nursing action?
A post-operative patient exhibits tachycardia, hypotension, and decreased peripheral pulses. Which condition should the nurse suspect FIRST?
A post-operative patient exhibits tachycardia, hypotension, and decreased peripheral pulses. Which condition should the nurse suspect FIRST?
A patient is receiving an isotonic crystalloid solution for fluid resuscitation. Which of the following assessment findings would indicate fluid overload?
A patient is receiving an isotonic crystalloid solution for fluid resuscitation. Which of the following assessment findings would indicate fluid overload?
Which intravenous fluid would be MOST appropriate for a patient with diabetic ketoacidosis (DKA)?
Which intravenous fluid would be MOST appropriate for a patient with diabetic ketoacidosis (DKA)?
A patient with a history of liver disease and increased intracranial pressure requires intravenous fluids. Which of the following solutions should be AVOIDED?
A patient with a history of liver disease and increased intracranial pressure requires intravenous fluids. Which of the following solutions should be AVOIDED?
A patient with end-stage renal disease (ESRD) misses their dialysis appointment and presents with muscle weakness, and an irregular heart rate. Which electrolyte imbalance is MOST likely the cause of these findings?
A patient with end-stage renal disease (ESRD) misses their dialysis appointment and presents with muscle weakness, and an irregular heart rate. Which electrolyte imbalance is MOST likely the cause of these findings?
Which function is NOT directly performed by the kidneys?
Which function is NOT directly performed by the kidneys?
A patient with acute kidney injury (AKI) is in the oliguric phase. Which of the following nursing interventions is MOST important?
A patient with acute kidney injury (AKI) is in the oliguric phase. Which of the following nursing interventions is MOST important?
A patient is diagnosed with acute glomerulonephritis. Which assessment finding is MOST consistent with this condition?
A patient is diagnosed with acute glomerulonephritis. Which assessment finding is MOST consistent with this condition?
A patient with nephrotic syndrome develops periorbital edema and frothy urine. What is the underlying cause of these manifestations?
A patient with nephrotic syndrome develops periorbital edema and frothy urine. What is the underlying cause of these manifestations?
A patient with polycystic kidney disease (PKD) is at increased risk for which of the following complications?
A patient with polycystic kidney disease (PKD) is at increased risk for which of the following complications?
Flashcards
Primary Aging
Primary Aging
Universal and normal aging processes.
Secondary Aging
Secondary Aging
Aging due to disease or environmental factors, not universal.
Frailty
Frailty
Geriatric syndrome with weight loss, exhaustion, and low activity.
Vitamin Needs in Older Adults
Vitamin Needs in Older Adults
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Fulmer SPICES
Fulmer SPICES
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The 4 M's
The 4 M's
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Dementia
Dementia
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Delirium
Delirium
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Age-Related Thermal Changes
Age-Related Thermal Changes
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Hypothermia Signs
Hypothermia Signs
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Watson's Caritas Processes
Watson's Caritas Processes
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Dyspnea Definition
Dyspnea Definition
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Helen Erickson's MRM Aims
Helen Erickson's MRM Aims
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Roy's Adaptation Model Process
Roy's Adaptation Model Process
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Adaptive Modes
Adaptive Modes
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Cultural Humility
Cultural Humility
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Adverse Event
Adverse Event
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Sentinel Event
Sentinel Event
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CUS Words
CUS Words
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Delegation Rights
Delegation Rights
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Nursing Ethics (ANA)
Nursing Ethics (ANA)
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Surgical Care Standards
Surgical Care Standards
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Malignant Hyperthermia
Malignant Hyperthermia
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Dantrolene Sodium (Dantrium)
Dantrolene Sodium (Dantrium)
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Moderate/Conscious Sedation
Moderate/Conscious Sedation
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Aldrete or Ramsay Sedation Scale
Aldrete or Ramsay Sedation Scale
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PACU
PACU
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PACU priority assessment
PACU priority assessment
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Aldosterone
Aldosterone
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ADH (Antidiuretic Hormone)
ADH (Antidiuretic Hormone)
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Dehydration Cues
Dehydration Cues
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Crystalloids
Crystalloids
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Kidney Functions
Kidney Functions
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AKI (Acute Kidney Injury)
AKI (Acute Kidney Injury)
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GFR (Glomerular Filtration Rate)
GFR (Glomerular Filtration Rate)
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Symptoms of Renal Calculi
Symptoms of Renal Calculi
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Lithotripsy
Lithotripsy
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Transduction
Transduction
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Transmission (Pain)
Transmission (Pain)
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Perception (Pain)
Perception (Pain)
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Modulation (Pain)
Modulation (Pain)
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Nociceptive Pain
Nociceptive Pain
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Neuropathic Pain
Neuropathic Pain
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Pain Assessment Mnemonic
Pain Assessment Mnemonic
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Multimodal Analgesia
Multimodal Analgesia
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Acetaminophen
Acetaminophen
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NSAIDs
NSAIDs
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Opioids
Opioids
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Anticonvulsants (for pain)
Anticonvulsants (for pain)
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Antidepressants (for pain)
Antidepressants (for pain)
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Capnography
Capnography
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Narcan
Narcan
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ACE Inhibitors in Heart Failure
ACE Inhibitors in Heart Failure
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ARBs in Heart Failure
ARBs in Heart Failure
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Cardiac Glycosides (Digoxin)
Cardiac Glycosides (Digoxin)
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HCN Channel Blockers (Corlanor)
HCN Channel Blockers (Corlanor)
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SGLT2 inhibitors in Heart Failure
SGLT2 inhibitors in Heart Failure
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Managing Pulmonary Edema
Managing Pulmonary Edema
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Atrial Fibrillation Treatment
Atrial Fibrillation Treatment
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Mitral Stenosis
Mitral Stenosis
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Mitral Regurgitation
Mitral Regurgitation
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Aortic Stenosis
Aortic Stenosis
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Treating Valve Disorders
Treating Valve Disorders
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Cardiomyopathy
Cardiomyopathy
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Infective Endocarditis
Infective Endocarditis
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Pericarditis
Pericarditis
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Rheumatic Carditis
Rheumatic Carditis
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Study Notes
- Information regarding older adults as follows
Aging Types and Subgroups
- Primary aging is universal and normal, whereas secondary aging results from disease and environmental factors.
- Age subgroups include:
- Young old (65-74 years)
- Middle old (75-84 years)
- Old old (85-88 years), also known as frail elderly
- Elite old (100+ years).
- Frailty in the elderly involves geriatric syndromes like weight loss, exhaustion, and low activity.
- Baby Boomers were born between 1946 and 1964.
- Older adults often experience increased malnutrition and dehydration, necessitating vitamins A, C, and D.
- Sensory changes in older adults include presbyopia, cataracts, macular degeneration, and glaucoma, along with reduced sensation (peripheral neuropathy) and arthritis.
- Older adults have an inability to tolerate standard medication doses, requiring cautious, gradual adjustments ("start low, go slow").
- They face an increased risk for depression, dementia, and delirium.
- NICHE (Nurses Improvement Care for Health System Elders) focuses on addressing sleep disorders, problems with eating or feeding, incontinence, confusion, evidence of falls, and skin breakdown (Fulmer SPICES).
- The 4 Ms of an age-friendly health system are:
- What Matters
- Medication
- Mentation (addressing depression, dementia, delirium)
- Mobility (assessing fall risk)
- Primary depression originates in the brain, while secondary depression is situational or related to chronic conditions, which are treated with psychotherapy and antidepressants (SSRIs).
- Tricyclic antidepressants are generally avoided due to their side effects, such as confusion, constipation, and urinary retention.
- Dementia is insidious and chronic, exemplified by Alzheimer’s disease, Lewy body dementia, and multi-infarct dementia.
- Delirium is an acute condition, often occurring in new settings, and can manifest as hypoactive, hyperactive, or a combination of both.
- PAD syndrome includes pain, agitation, and delirium.
- The Confusion Assessment Method (CAM) is used to assess delirium.
- Assess for UTI or hypoxia.
- Treatment involves addressing the underlying condition and maintaining a calm environment.
Thermal Regulation Changes
- The body maintains a stable core temperature of 97 to 99°F.
- Responses to cold involve shivering, contraction, increased heart rate, peripheral vasoconstriction, dilation of blood vessels and muscles, insulation by subcutaneous fat, and release of thyroxine/corticosteroid.
- Altered responses to cold in older adults can include a lower core temperature, inefficient physiological responses, decreased likelihood of taking corrective actions, and increased risk for accidental hypothermia.
- Responses to heat include sweat and dilation of peripheral blood vessels.
- Altered responses to heat include delayed/diminished sweating, inaccurate perception of temperature, and risk of heat exhaustion (caused by low fluid, sodium, or both) and heat stroke (more serious due to the inability to balance heat production and dissipation).
- Age-related changes affecting thermal regulation include inefficient vasoconstriction, lower cardiac output, decreased subcutaneous tissue/muscle mass, diminished shivering and acclimatization, and altered peripheral circulation and sweating.
- Risk factors affecting thermal regulation include environmental conditions, housing, medication/alcohol use, inactivity, and social isolation.
- Baseline temperature must be known, as older adults may run normal or low temperatures even in the presence of infections, which may manifest as impaired cognition/confusion.
- Hypothermia is detected by core body temperature, cool skin in unexposed areas, lethargy, slurred speech, mental changes, impaired gait, slow/irregular pulse, low blood pressure, and slow/shallow respirations.
- Hyperthermia symptoms include lethargy, headache, nausea, loss of appetite, warm/dry skin (without sweating), dizziness, dyspnea, tachycardia, vomiting, diarrhea, muscle cramps, and confusion.
Theories
- Watson's Caritas Process involves:
- practicing loving kindness
- authentic presence
- cultivating spirituality and openness
- developing helping-trusting relationships
- supporting feelings
- creative use of self
- teaching/learning experiences
- healing environment
- basic needs
- openness to the mysterious.
- Dyspnea is breathlessness, assessed subjectively using the Borg Scale, prevented with anxiety reduction, and treated through various methods, although O2 may not always help.
- Helen Erickson's MRM (Modeling and Role-Modeling) 5 Aims:
- promote trust
- positive orientation
- control
- affirmed strengths
- mutual health-directed goals
- Pain is subjective and should be assessed often.
- Roy’s Adaptation Model 6-step Nursing Process involves:
- assessing behaviors related to adaptive modes
- identifying stimuli (focal, contextual, or residual)
- diagnosing adaptive state
- setting goals promoting adaptation
- implementing interventions related to stimuli
- evaluating goals.
- Adaptive modes include physiological, self-concept, role function, and interdependence (significant others and support system).
- Stimuli are classified as:
- Focal (immediately confronting the individual)
- Contextual (all others contributing to focal)
- Residual (environmental effects unclear)
Med-Surg Nurse Role
- Cultural humility is the recognition of implicit bias.
- Cultural competence involves tailoring care to diversity.
- Joint Commission's safety goals include identifying patients correctly, improving communication, ensuring medication safety, managing alarm safety, and preventing infection.
- Just culture emphasizes blame-free improvements.
- Adverse events are variations from the standard of care.
- Sentinel events are severe variations causing death or major harm.
- TeamSTEPPS includes strategies and tools to enhance performance and patient safety.
- CUS words: I'm Concerned, I'm Uncomfortable, I don't feel Safe.
- Check backs involve repeating information for clarity.
- Callouts ensure all team members hear important information.
- The 2-challenge rule involves stating a concern twice and then following the chain of command.
- Delegation involves the right task, circumstance, person, communication, and supervision.
- Core measures are evidence-based practices for quality.
- Quality improvement (PDSA) includes plan, do, study, act.
- Clinical judgment measurement model is based on the scientific method.
- Healthcare disparities relate to populations; social determinants of health relate to locations.
- Ethics for nurses (ANA):
- Autonomy (involvement)
- Beneficence (doing good)
- Non-maleficence (do no harm)
- Fidelity (promise keeping)
- Veracity (truth telling)
- Social justice (equality)
- Moral distress is an ethical dilemma related to systemic constraints.
Perioperative Information
- Standards in surgical care:
- Prophylactic antibiotics within one hour of surgery and discontinued within 24 hours after
- Controlled 6 AM post-op blood glucose for cardiac surgery patients
- Appropriate hair removal
- Catheter removal by post-op day 1
- Perioperative temperature management
- Beta-blocker continuation perioperatively
- VTE prophylaxis one day before and after surgery
- ASA Status:
- I: Healthy patient
- II: Mild systemic disease
- III: Severe systemic disease
- IV: Severe systemic disease that is a constant threat to life
- V: Low chance of survival without operation
- VI: Declared brain dead patient whose organs are being removed for donation
- Autologous blood donations can occur up to five weeks before surgery (infection-free, hemoglobin greater than 11, with order).
- Donations can be made every three days (2-4 units)
- Donations cannot be made within 72 hours of surgery.
- Informed consent involves mostly review; a patient may sign with an “X” with two witnesses, and a surrogate is optional if incapacitated/incompetent.
- Consent can be given by phone with two witnesses (same for blind signatures).
- NPO status prevents aspiration.
- Medications may be held or not.
- Enemas and laxatives protect the colon. Clippers are used for hair removal.
- Education covers tubes/drains/vascular access.
- Prevent respiratory complications with:
- Incentive spirometry
- Deep breathing and coughing
- Splinting
- Lower leg exercises
- VTE prevention includes anticoagulant/platelet medications, TED hose/PCD/SCDs, leg exercises, and mobility.
- Preoperative medications include:
- Sedatives
- Hypnotics
- Anxiolytics
- Opioid analgesics
- Anticholinergics
- Antibiotics
- Histamine receptor blockers
- The surgical team:
- Surgeon
- Surgical assistant
- Anesthesiologist
- CRNA
- Holding area nurse (assesses physical/emotional status, verifies orders/checklist/consent)
- Circulating nurses (advocate, timeout, monitor/communication with team)
- Specialty nurses
- Hand scrub duration: 3 to 5 minutes.
- General anesthesia causes a reversible loss of consciousness by inhibiting the CNS (analgesia, amnesia, unconsciousness with loss of muscle tone/reflexes).
- It may be inhaled, IV, or balanced (combination).
- Stages:
- 1: Analgesia, sedation, and relaxation
- 2: Excitement, delirium
- 3: Operative or surgical anesthesia
- 4: Dangerous
- Malignant hyperthermia is a life-threatening complication related to anesthesia where skeletal muscle exposed to drugs increases muscle metabolism and leads to increased calcium in muscle cells.
- Results in acidosis/cardiac dysrhythmia/high body temperature
- Can happen immediately or hours later.
- Manifestations: tachycardia, dysrhythmias, jaw and upper chest muscle rigidity, hypertension, tachypnea, mottling/cyanosis, myoglobinuria.
- Early indicator: unexpected rise in end-tidal CO2 and tachycardia. A late sign is a temperature as high as 111.2°F.
- Treatment: stop inhalation agents/Succinylcholine, intubate, ventilate with 100% O2, administer Dantrolene Sodium (Dantrium) IV 2-3mg/kg.
- Terminate surgery if possible, or continue with an anesthetic not related to malignant hyperthermia, and use cooling techniques.
- Other complications of anesthesia include overdose, hypotension, hypoventilation, broken teeth/lip/mouth/vocal cord trauma.
- Other types of anesthesia: local (topical) and regional (field, nerve block, spinal, epidural).
- Moderate/conscious sedation involves IV delivery of sedative, hypnotic, and opioid drugs to reduce consciousness while maintaining the airway and allowing response.
- Used in short procedures!
- A nurse may deliver it with position supervision, monitoring airway, consciousness, capnography, ECG status, and vitals every 15-30 minutes.
- Recovery LOC is measured with Aldrete or Ramsay Sedation Scale.
- PACU involves evaluation/stabilization to prevent and manage complications.
- Monitor LOC, temperature, pulse, respiration, oxygen saturation, and BP, and assess the incision site, using a modified Aldrete/post anesthesia discharge scoring system scale (1-10).
- Priority assessment: patent airway and gas exchange.
- Cardiovascular assessment: BP & pulse q 15min until stable, report BP changes 15-20 mmHg +/-, bradycardia r/t anesthesia/hypothermia, tachycardia r/t blood loss, shock, pain.
- Also assess distal pulses and implement VTE prophylaxis.
Fluid Balance
- Aldosterone from the adrenal glands promotes Na and H2O retention.
- ADH from the pituitary gland promotes kidneys to retain H2O.
- ANP (atrial) and BNP (ventricle) increase urine output through baroreceptors.
- Dehydration involves loss and third spacing, indicated cues: decreased BP/peripheral pulses/weight (1L=1kg), and increased HR/RR/mental or urine changes.
- Treat with oral or IV replacement.
- IV fluids: crystalloids (increase intravascular/interstitial fluid).
- Isotonic solutions (.9NaCl, Lactated Ringers, D5W) treat FVD from vomiting, diarrhea, hemorrhage, drainage, hyponatremia, or with blood products.
- Lactated Ringers are used for fluid resuscitation, burns, GI loss, blood loss, or hypovolemia related to shifts.
- D5W is free water that dilutes extracellular fluid and is used by cells for energy.
- Isolytes are alkalizing agents.
- Hypotonic solutions (1/2 & 1/4 strength NaCl) treat diabetic ketoacidosis and hyperosmolar hyperglycemic state.
- Don’t use in increased ICP, liver disease, trauma, or burns.
- Hypertonic solutions (3% NaCl & D10W) require caution due to risk of fluid volume overload and pulmonary edema.
- Colloids are big molecules (albumin/dextrans) that can’t pass membranes.
- Draw fluid intravascularly for hyponatremia/malnutrition.
Renal System
- Kidneys Maintain fluid volume/composition, eliminate waste, regulate BP, maintain acid/base balance, produce erythropoietin, and convert Vitamin D to active form.
- AKI (Acute Kidney Injury) causes an inability to filter blood, while CKD (Chronic Kidney Disease) is gradual.
- GFR (125 mL/min) is controlled by BP.
- Hypercalcemia increases absorption and decreases excretion.
- Hyperoxaluria is a genetic high oxalate production or excess from food (spinach, cocoa, beets, peanuts, pecans, okra).
- Hyperuricemia is related to gout/thiazide diuretics.
- Symptoms of renal issues: renal colic, N/V, pallor, diaphoresis, frequency, dysuria, oliguria/anuria/hematuria.
- Treat with:
- Opioids
- NSAIDs (caution in renal insufficiency)
- antispasmodics
- Hydration
- Antibiotics treat infection or struvite (bacteria-based) stones.
- Lithotripsy uses sound waves synchronized with the ECG R wave. Also stent, ureteroscopy (to grab stones), percutaneous ureterolithotomy (through the skin).
- Hydronephrosis is kidney enlargement, while hydroureter is ureter enlargement.
- Acute pyelonephritis is a bacterial infection (E. Coli) that can impair the kidney, causing systemic symptoms like fever, chills, N/V, CVA tenderness, burning/urge/frequency, nocturia, and malaise/fatigue.
- Chronic pyelonephritis is caused by structural issues, stasis, obstruction, or reflux.
- The kidney exhibits features like HTN (Hypertension), hyponatremia, lowered urine concentration, and hyperkalemia/acidosis.
- Glomerulonephritis is an inflammation that injures the glomerulus, allowing protein passage, which is associated with HTN, progressive kidney damage, edema, and anemia.
- Primary glomerulonephritis: kidney only, usually infections.
- Secondary glomerulonephritis: related to diabetic nephropathy, SLE, Sickle cell.
- Look for edema, pulmonary edema, SOB, Crackles, S3, JVD, bloody urine, oliguria, dysuria, HTN, N/V, fatigue. -Treat with antibiotics, immune suppressants, fluid/electrolyte balance (restrict Na/H20) & restrict K/protein (elevated BUN)
- Chronic glomerulonephritis develops over years, causing proteinuria, hematuria, fatigue, and occasional edema, eventually leading to end-stage renal damage.
- Look for fluid volume overload, edema, SOB, crackles, tachycardia, S3 sounds, and JVD. Uremic (elevated BUN) slurred speech, ataxia, tremors, asterixis (hand tremors) or can’t hold flexed hand, also, dry skin, itching rash, yellowing.
- Nephrotic syndrome is an immunologic disorder with increased glomerular permeability, massive proteinuria, hypoalbuminemia, facial/periorbital edema, lipiduria/hyperlipidemia, and increased BUN/Creatinine with decreased GFR.
- Good GFR=Give Protein
- Poor GFR= Don't Give Protein
- Polycystic Kidney Disease (PKD) is autosomal dominant, causes cysts, enlarges kidneys, and damages structures.
- HTN (Hypertension) is common due to ischemia.
- Symptoms include abdominal/flank pain and distention, HTN, nocturia, bloody/cloudy urine, and sodium wasting/inability to concentrate urine; progresses to kidney failure with anuria.
- Manage BP with Acetaminophen
- reduce infection, dehydration, and constipation.
Independent Study: Pain
- Pain is subjective (leading cause of disability).
- Gate Control Theory: CNS based, impulse ascends to brain if open, can be blocked at dorsal horn
- Nociception:
- Transduction: Noxious event activates neurons>impulse travel>release Ions/Neurotransmitters>Stimulation=excitatory compound (serotonin, Bradykinin, Histamine, Substance-P.
- Transmission: Axons (A=fast;C = slow)
- Perception: Impulse transmitted to brain for perception (Opiod target)
- Modulation: Descending signals from neurotransmitters block part or all of transmission (Anticonvulsant/depressant target)
- Nociceptive Pain: Normal, broken up into somatic which is skin/musculoskeletal, and visceral which is organs. Neuropathic Pain: SNS/PNS damage (can occur w/o tissue damage/inflammation) resists 1st line analgesics. Acute pain is a warning sign and localized, while chronic pain lasts for >3 months.
- Assess pain using COLDSPAT/SOCRATES.
- Multimodal Analgesia: opioid/non-opioid/Adjuvant
- Acetaminophen: CNS, Analgesic/antipyretic (hepatotoxic) 4g max dose (3g in elderly). IV for pain/fever over 15min.
- NASID: Renal precaution, Platelet aggregation inhibition (no hemo/chemo). Gastric irritation/ulcers, so block prostaglandin use.
- Opioid: attach to opioid receptors for moderate-severe (burn/trauma/surg).
- Constipation is common but fixed with a stool softener
- Nausea is managed with antiemetic
- Pruritus use narcan
- Sedation, respiratory depression (watch for snoring);
- Morphine is the gold standard
- Dilaudid is 5x stronger,
- Fentanyl is used for end-organ failure
- Opioid agonist/antagonist:
- Withdrawl risk
- Has a celing effect
- Can reverse Opioid side effects
- Opioid naive is when you are lightweight, where as tolerant is
- Adjuvants: off-label use.
- Anticonvulsant: block Na/Ca to reduce pain transmission “Gabas”.
- Norepi. & Serotonin (block reuptake of inhibitory nerochems)
- Muscle Relaxants are used to treat pain.
- Reassess 15-30min post IV, 30-60min post Oral.
- Capnography: measures CO2 (better marker than SPO2)
- Narcan (0.4-0.8mg): for resp. Depression, blocks opiates.
- Dependance: withdraw;Tolerance: need more; Addiction:misuse.
- Integrative Modalities: Allopathic (traditional), Complementary, & Alternative methods.
- Physical (acupuncture, massage, chiropractic, PT)
- Behavior: Cog.Behavioral(Humor, imagery, distraction, meditation)
- Biology (herbs , Vitamins)
- Cog.Behavioral(Humor, imagery, distraction, meditation)
- Energy (reiki, healing touch , magnets )
Basic ECG
- Automaticity: pacing;
- excitability:non-pacemaker cells depolarize;
- conductivity: cell to cell electrical stimulus;
- depolarization: (-) charge cells develop (+);
- contractility: mechanical activity.
- conduction order:
- SA Node(P Wave
- Pacemaker 60-100BPM)>AV Node (PR Interval)>Bundle of His>L/R Branch>Purkinji Fibers.
- ECG: Clouds over Grass/Smoke over fire, (B)rown is (B)etween
- NSR: 60-100, regular, P present, PR=0.12-0.20, QRS: 0.04-0.10
- A-Fib: most common (irregular Vent. Response 120-220bpm)
Cardio
- Cardio blood flow: VC>RA>Tri. Cusp>RV>PArt.>Lung>PV>LA>Mitral>LV>AValve>Aorta Coronary Arteries: Named after location (right, left, circumflex, posterior, marginal.
- Diastole=relax
- Systole=contract
- CO: is (4-7L/min).
- Stroke vol is the amount pumped from vent. Per beat.
- Ejec. Fraction is 65%
- Preload: Vol. in ventricle;
- Afterload is Resistance in Aorta
- Arteriosclerosis: harden arteries Atherosclerosis: plaque
- Cholesterol: 55
- LDL: 150/90 for under 60 yrs 140/90 for +60yrs
- HTN meds can be thiazide>CCB>Ace inhib.>ARB for Non-african decent...
- African decent: thiazide>CCB
- BP regulators: AND: ups SNS
- Baroreceptors: stretch=reaction;
- Chemoreceptors: hypoxia triggers vagus nerve to vasoconstrict;
- Fluid Vol.: ^systemic Arterial BP^diuresis; Kidneys: RAAS;
- Endocrine: hormone release to^SNS.
- Etiology of HTN comes from Family, AA ethnicity, HLD, lifestyle 2ndary: Kidney disease, Primary Aldosteronism, preggos, hormones/corticoids. *malignant HTN: >200/>130
- HTN management: Diuretics (Thiazide HCTZ: inhibit Na/Ch/H2O reabsorb>promote Potassium excretion Can treat kidney stone/bone loss
- K sparring: Aldactone(inhibits Na reabsorption in exchange for K) monitor thiazide/loop for HypoK+ & HyperK+ in K+ sparring) CCBs: block Ca>cells & SA/AV conduction *monitor avoid Grapefruit ACE-I: lowers Na/H2O reabsorb may have dry,hacking cough ARBs: Stop Angio II in vascular smooth & Adrenal monitor for HyperK+/avoid K+. Beta Blockers (cardioselective: lower HR/contractility 1st line for CADMetroprolol DM>. masks hypoglycemia. HCNs lowers HR in Sinus node. SGLT2i increase urine output (excrete glucose) reduce preload/afterload, sodium.
- Manage dyspnea, anxiety, change in mentality.
- Assess a fib is embolus + increased risk of HF.
- For A-Fib: antidysrythmics are given (CCBsZem’s, Amiodarone, B-Blockersolol, Dig, Flecainide.)
- Mitral stenosis: causes dyspnea. orthopnea, Paroxysmal nocturnal dyspnea, pulmonary edema. Mitral regurgitation causes exertional dyspnea, palpitations, atypical chest pain, A-Fib, & S3 sounds possible. Treat all valve disorders with Prophylactic antibiotic before invasive procedure, also diuretics, B-blockers, Dig, O2, valve repair/replacement. Cardiomyopathy can by viral caused. Treat dilated by lowering sodium, managing stress/worry. Infective Endocarditis is a microbial infection. Treatment: IV antimicrobials (penicillin/cephalosporin) x4-6wks &valve repair/replacement. Pericarditis: Inflammation. May be related to MI Assess substernal chest pain radiates to left shoulder/back. For Rheumatic Carditis Treat: Penicillin (or erythromycin in allergic patients) IV Peripheral Vascular disease is caused by DM, high chlosterol. Causes muscle pain/cramps Symptoms include; thick toenails, dry skin, thin hair Varicose Veins happens with incompetent causes leg elevation, and managment is laser surgry.
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