Vulnerable Patients: Informed Consent & Legal Rights

• Nurses ensure patients' legal rights, especially for vulnerable patients. Legal requirements for nurses regarding patient vulnerability and healthcare settings.
• Informed consent is valid if given freely by a competent patient, provided in writing, with full understanding of the information.

Informed Consent Must Include

• Explanation of the procedure and associated risks.
• Discussion of benefits and alternatives.
• Opportunity for questions.
• Right to withdraw at any time.

Informed Consent is Required For

• Invasive procedures.
• Radiation therapies.
• Risky non-surgical procedures.
• Sedation and anesthesia.
• Blood and blood product administration.

Definition of Vulnerability

• Vulnerability means being exposed to potential harm, physically or emotionally.
• Vulnerability is often seen as negative but can heighten awareness, encourage caution, and enhance empathy.

Manifestations of Perceived Vulnerability/Weakness

• Elder speak.
• Infantilization.
• Pathologizing behavior.
• Removal of patient choices and autonomy.
• Stemming from environmental, social, psychosocial, and physical conditions.

Types of Hierarchy in Healthcare

• Social determinants of health.
• Social position and perceived vulnerability.
• Generational vulnerability.

Vulnerability vs. Resilience

• Vulnerability relates to frailty, while resilience is adapting and overcoming challenges.
• Nurses balance their vulnerability with emotional monitoring to provide empathetic care.

Categories of Surgery

• Emergent: Requires immediate action.
• Urgent: Must occur within 24-30 hours.
• Required: Planned within weeks or months.
• Elective: Not life-threatening if not performed.
• Optional: Based on patient preference.

Surgical Classifications

• Diagnostic: Biopsy, exploratory procedures.
• Curative: Tumor excision.
• Reparative: Aortic dissection.
• Reconstructive/Cosmetic: Structural repairs.
• Palliative: Symptom relief without curing disease.

Pre-Op Surgical Checklist

• Medication history (anticoagulants, NSAIDs, steroids).
• Baseline vital signs.
• Screening for malignant hyperthermia.
• Patient identification and allergy verification.
• Consent confirmation.
• NPO status verification.
• Patient preparation (gown, voiding, denture removal).
• Correct IV placement and site marking.
• Lab value verification.

Pre-Operative Considerations

• Common Diagnoses: Anxiety, fear, knowledge deficit, risk of adverse reactions, incomplete consent
• NPO Guidelines:
• Adults: No solids after midnight, clear fluids up to three hours before surgery
• Pediatrics: Formula up to six hours prior, breast milk four hours, clear fluids three hours

Pre-Operative Medications

• Anxiolytics: Sedation and amnesia (lorazepam).
• Narcotics: Pain relief (morphine, fentanyl).
• Gastric Acid Blockers: Reduce aspiration risk (pantoprazole, sodium citrate).
• Antiemetics: Prevent nausea/vomiting (ondansetron, dimenhydrinate).
• Antibiotics: Prophylactic infection prevention (cefazolin).

Surgical Team Members

• Patient, surgeon, anesthetist, nurses, surgical technicians.

Nursing Roles in Surgery

• Scrub Nurse: Maintains sterile field, anticipates supply needs, performs surgical counts.
• Circulating Nurse: Manages OR environment, ensures safety, verifies consent.
• RN First Assistant: Assists with suturing, cutting, tissue handling.
• Nurse Anesthetist: Administers anesthesia, intubates patients, monitors status.

Intraoperative Complications

• Nausea/vomiting.
• Anaphylaxis.
• Hypoxia/respiratory complications.
• Hypothermia.
• Malignant hyperthermia.

Intraoperative Medications

• Narcotics: Pain relief (morphine, fentanyl).
• Benzodiazepines: Sedation and amnesia (midazolam).
• Gastric Acid Blockers: Increase gastric pH (pantoprazole).
• Antiemetics: Prevent nausea (ondansetron).
• Anticholinergics: Reduce secretions (atropine).
• Anesthetics: Induce unconsciousness (propofol, halothane).
• Neuromuscular Blockers: Paralysis for surgical procedures (high-alert medications).

Post-Op Assessment Priorities

• Vital signs, respiratory function, mental status.
• Pain control, wound assessment, urine output.
• Emotional status, complications, surgical area integrity.

Post-Operative Risks

• Respiratory issues (atelectasis, pneumonia, PE, aspiration).
• Neurological (delirium, stroke, chronic pain).
• Skin (pressure ulcers, infection, dehiscence).
• GI (paralytic ileus, constipation, bowel obstruction).
• Urinary (retention, incontinence, UTI).
• Cardiovascular (DVT, hemorrhage, hematoma).
• Functional decline (fatigue, weakness, mobility issues).

Pain Management: Patient-Controlled Anesthesia (PCA)

• Allows self-administration of IV or epidural pain relief.
• Prevents overdose with a lock-out mechanism.
• Requires monitoring for LAST (local anesthetic systemic toxicity).

Acid-Base Balance

• Lungs: Excrete CO2 via exhalation.
• Kidneys: Regulate H+ and HCO3- levels.
• Buffer Systems: Bicarbonate and phosphate buffers maintain pH.

Complications of Nausea/Vomiting

• Aspiration pneumonia, dehydration, malnutrition.
• Metabolic disturbances, increased intracranial pressure.

Oral Rehydration Formula

• 1L water, 8 tsp sugar, 1 tsp salt, mashed banana.

GI Disorders

• Peptic Ulcer Disease: Erosion of Gl wall, increased sepsis risk.

• Crohn's Disease: Chronic inflammatory disease of the Gl tract.

• Ulcerative Colitis: Inflammatory condition of the colon and rectum.

Medication Considerations in Older Adults

• Avoid benzodiazepines, scopolamine, metoclopramide due to delirium risk.

• Higher susceptibility to dehydration and complications.

• Causes of Dyspnea Cardiac dysfunction, heart disease, pericarditis, arrythmia. Airway obstructive diseases, infections, PE, pleural disorders, acidosis, anemia, anxiety, etc.

• Physiological Response Hypoxia/Hypercapnia causes increased rate and depth. Increased WOB causes accessory muscle use. Sympathetic (Fight or Flight) causes tachycardia and diaphoresis.

• Priority Problems

1. Impaired Gas Exchange
2. Ineffective Breathing Pattern
3. Risk of Resp Failure
4. Anxiety and Fear

• Risk Factors: Smoking, personal history, family history, allergens, poor nutrition, substance abuse, stress, lack of exercise.
• Testing: O2 Saturation, Hgb, CXR, RBC, WBC, ABGs, cultures, bronchoscopy, PFTs.
• Medications: Bronchodilators, opioids, benzodiazepines, corticosteroids, O2.

Respiratory Pharmacology

• Inhaled Drugs

1. Metered Dose Inhalers - One minute in-between doses with spacers.
2. Respimat - Fine mist.
3. Dry Powder Inhalers - Micronized powder that is breath activated.
4. Nebulizers - Mist.

• Short Acting Beta 2 Agonists Smooth muscle relaxation causing bronchodilation. Used for bronchospasm in asthma or COPD. Can cause tachycardia, angina, tremor. Avoid use in MAOIs. Salbutamol (Albuterol) - Ventolin

• Long Acting Beta 2 Agonists Bronchial smooth muscle relaxation causing bronchodilation. Long term control of bronchospasm in asthma or COPD. Fixed schedule not PRN. Must be given with a glucocorticoid. Increase risk of death with monotherapy asthma. Salmeterol

• Anticholinergics Blocks receptors in the bronchi to reduce bronchoconstriction. Slower onset COPD and off label for asthma. Side effects of dry mouth, throat, nasal congestion. Caution in patients with glaucoma and prostate enlargement. Ipratropium - Tiotropium

• Inhaled Corticosteroids Suppresses inflammation, decreased inflammatory response, edema of airway mucosa. Indicated for asthma and COPD exacerbation. Side effects include Candidiasis, dysphonia. Beclomethasone - Fluticasone Budesonide

• Leukotriene Receptor Antagonists Suppresses leukotrienes which decreases inflammatory response. Decreases bronchoconstriction. Maintenance in chronic asthma. Can cause neuropsychiatric effects. Zafirlukast - Montelukast

• Monoclonal Antibodies Modulates immune response using specific pathways to reduce inflammation. Asthma with some COPD. Can cause injection site reactions and headaches, back pain. Contraindicated with hypersensitivity. Omalizumab

• Opioids Low doses can reduce perception of dyspnea (morphine sulfate).

• Antitussives Cough suppressants, should only be given for ongoing, dry, nonproductive cough. Codeine

• Mucolytics Reduce viscosity of secretions for easy removal, breaks down chemical structure of mucus.

• Bronchiolitis Inflammation of the fine bronchioles & small bronchi. Lower respiratory tract infection. Often due to RSV. Mostly affecting children under 2 years. Initial: Rhinorrhea, Pharyngitis, Coughing, Wheezing, Eye and Ear Drainage, Fever. Progression: Increased coughing and wheezing, tachypnea and retractions, cyanosis. Severe: Tachypnea, listlessness, apnea, decreased breath sounds.

• Asthma Pulmonary function tests. FEV1 - Forced expiratory rate in one second. FEV1/FVC - Ratio less than 70% indicating airflow obstruction. Pediatric Respiratory Assessment Measure Valid screening tool for children 1-17. Score severity based on response to treatment. Criteria - O2 Sats - Suprasternal Retractions - Scalene Muscle Contractions Air Entry - Wheezing Score from 0-3 Mild 4-7 Moderate 8-12 Severe

• Complications of Asthma: Status asthmaticus, respiratory failure, pneumonia.

• COPD Includes diseases like chronic bronchitis and emphysema. Caused by lung tissue damage and scar formation. Excess mucus production leading to hyperinflammation.

• Risks and Causes Tobacco smoke, dust and chemicals, pollution, factors effecting lung growth, alpha 1 antitrypsin deficiency.

• Symptoms Sputum production, dyspnea, rigid chest, clubbing, weight loss, limited ADLs.

• COPD Staging Mild: 80% FEV1 Moderate: 50-79% Severe: 30-49% Very Severe: 29% or Less

• Complications: Respiratory failure, infection, atelectasis, pneumothorax, cor pulmonale r/t pulmonary hypertension.

• BIPAP BiPAP stands for Bilevel Positive Airway Pressure. IPAP and EPAP.

• Renal Buffering Systems Bicarbonate reabsorption. H secretion and excretion. Ammonia buffering. Phosphate acts as urinary buffer to H.

• Key Terms Oliguria - Urine output less than 400ml in 24hr. Anuria - Output less than 50ml in 24hr. Azotemia - Accumulation of Nitrogen in blood. Uremia - Azotemia with toxic symptoms (fatigue, N/V, itchy skin).

• Acute Kidney Injury AKI Rapid loss of kidney function due to kidney damage. Decreased GFR and increased Creatinine. Usually a reversible cause like hypovolemia, hypotension, decreased CO, inflammation.

• Risk Factors: Diabetes, vascular disease, age, NSAIDS, blood loss, chemotherapy, infection.

• Type of Damage Severity - Location - Phases

• Types of Acute Renal Failure

• 1. Prerenal Hypoperfusion of kidney, volume depletion, impaired CO, vasodilation.

• 2. Intrarenal Prolonged renal ischemia, nephrotoxic agents, infection, parenchymal clot or atherosclerosis.

• 3. Postrenal Calculi, tumors, BPH, strictures, blood clots.

• Rifle Classifications R - Increased creatinine 1.5x or decreased GFR 25%. I - Increased serum creatinine 2x GFR decreased by 50%. F - Increased creatinine 3x baseline or decreased GFR 75%. L - Persistent acute kidney injury = complex loss of kidney function. E - ESKD.

• Phases of Acute Renal Failure Initiation Period - Initial insult, no change in urine output. Oliguria Period - Increased levels of urea, creatinine, uric acid, K+, Mg. Diuresis Period - Renal fxn improved, increased urine output, improvement in labs, may still have uremic symptoms, dehydration. Recovery Period - Takes 3-12 months, improvement in renal function, normal labs. AKI can cause hyperkalemia which can cause muscle weakness, numbness, chest pain, SOB, N/V, arrythmias.

• Interventions for Hyperkalemia*: Sodium polystyrene (Kayexalate), IV dextrose or insulin, albuterol. AKI can cause high phosphate (symptomless) low calcium levels which causes cramps, tingling, fatigue.

• Clinical Manifestations of AKI Symptoms of uremia, confusion, decreased LOC, headache, muscle weakness, seizures, decreased BP. ACE-I and ARBs are a major factor for hypovolemia.

• Pharmacologic Interventions for Chronic Kidney Disease Antihypertensives in low doses ACE-Is. Diuretics like furosemide and other loop diuretics (monitor electrolytes). Eprex EPO CKD requires lower doses of all renal filtered medications.

• Dialysis is indicated for fluid overload, hyperkalemia and acidosis, advanced uremia, confusion, toxin removal.