Adult Health I Chapter 9 Lecture PPT PDF

Welcome to N60A: ADULT HEALTH I Randy B. Shields, Jr., MSN-CNL, RN, CCRN Professor of Nursing Chabot College Nursing Program  Adult Health I: The Foundation of Nursing Practice  Adult Health I is a cornerstone of your nursi...

Welcome to N60A: ADULT HEALTH I Randy B. Shields, Jr., MSN-CNL, RN, CCRN Professor of Nursing Chabot College Nursing Program  Adult Health I: The Foundation of Nursing Practice  Adult Health I is a cornerstone of your nursing education, forming the bedrock upon which all future learning and practice are built. This course is not just another step in your journey; it’s the foundation that supports your transition from nursing student to professional nurse. 2  Why is this course so vital?  Core Knowledge and Skills: Medical-Surgical Nursing, the focus of Adult Health I, is the backbone of the nursing profession. The principles and practices you will learn here apply to a wide range of patient care scenarios, from acute to chronic conditions, and across various healthcare settings. Mastery of this content ensures that you can provide high-quality care to adult patients, regardless of their specific medical needs.  Integration of Critical Concepts: This course emphasizes the integration of pathophysiology and pharmacology—two pillars of effective nursing care. Understanding how diseases affect the body (pathophysiology) and how medications work to treat these conditions (pharmacology) is essential for making informed clinical decisions. These concepts will be interwoven throughout the course, ensuring that you not only understand the 'what' but also the 'why' behind your nursing interventions. 3  Preparation for Advanced Practice: The knowledge and skills you gain in Adult Health I will prepare you for more specialized areas of nursing, such as critical care, emergency nursing, or advanced practice roles. This course lays the groundwork for these future endeavors by providing you with a deep understanding of the complexities of adult patient care.  Holistic Patient Care: Beyond the technical skills, this course emphasizes the importance of holistic, patient- centered care. You will learn to consider not just the physical, but also the emotional, social, and psychological needs of your patients, a critical aspect of nursing that will serve you throughout your career. 4 INTRODUCTION AND INCORPORATION OF PATHOPHYSIOLOGY AND PHARMACOLOGY 5 Pathophysiology and Pharmacology: The Cornerstones of Clinical Decision-Making In Adult Health I, pathophysiology and pharmacology are not standalone topics but are integrated into every aspect of the course. Understanding the disease processes (pathophysiology) and the medications used to treat them (pharmacology) is essential for delivering safe, effective, and compassionate care. Here’s how these elements are incorporated into your learning experience: 6  Preoperative Phase Pathophysiology: We will explore how chronic conditions like hypertension, diabetes, and cardiovascular disease influence surgical outcomes. Understanding these conditions helps you anticipate complications and tailor your nursing care accordingly. Pharmacology: We’ll discuss the preoperative management of medications such as beta-blockers, anticoagulants, and insulin. You’ll learn when to continue, adjust, or pause these medications, and understand the rationale behind these decisions. 7 Intraoperative Phase Pathophysiology: During surgery, understanding the body’s physiological responses to anesthesia and surgical stress is critical. We’ll cover how different organ systems react under anesthesia and how these responses can be managed. Pharmacology: You’ll delve into the pharmacodynamics and pharmacokinetics of anesthetics, neuromuscular blockers, and adjunct medications. This knowledge will enable you to anticipate and manage potential complications, ensuring patient safety. 8 Postoperative Phase Pathophysiology: In the recovery phase, you’ll study the common postoperative complications such as respiratory depression, thromboembolism, and infection. Understanding the underlying pathophysiology of these complications is key to early detection and intervention. Pharmacology: Pain management, anticoagulation therapy, and the use of antiemetics are just a few of the pharmacological interventions you’ll learn to apply. We’ll discuss how to balance efficacy with safety, considering factors such as patient history and concurrent medications. 9 Case Studies and Clinical Application  Throughout the course, case studies and group discussions will help you apply the principles of pathophysiology and pharmacology in real-world scenarios. These exercises are designed to reinforce your understanding and develop your critical thinking and decision-making skills. 10  Why This Matters  The integration of pathophysiology and pharmacology into every lecture, discussion, and assignment ensures that you gain a comprehensive understanding of the conditions you will encounter in clinical practice. This approach prepares you not just to pass exams, but to excel in your clinical rotations and beyond, equipping you with the knowledge and skills to provide exceptional care to your patients. In summary, Adult Health I is a pivotal course that bridges the gap between theory and practice, integrating pathophysiology and pharmacology into the heart of your nursing education. This comprehensive approach ensures you are well-prepared to meet the challenges of your future nursing career. 11 Concepts of Care for Perioperative Patients CHAPTER 9  Concepts  The priority concept in this chapter is  Gas exchange  Pain  The interrelated concepts in this chapter are  Infection  Tissue integrity  Overview Surgery is performed for many purposes, from diagnosis to cure Preoperative phase Nurses provide care before, during, and after surgery Intraoperative phase (the perioperative experience) Postoperative phase Inpatient versus outpatient (ambulatory) AORN (Association of Perioperative Nurses) www.aorn.org Safety During  National Patient Safety Goals the Surgical  SBAR Experience  Surgical Care Improvement Plan (SCIP)  Surgical Safety Checklist  TeamSTEPPS PREOPERATIVE PHASE  Preoperative Phase  Begins when patient is scheduled for surgery; ends at time of transfer to surgical suite  Focus is on preparing for surgery and ensuring safety  Preoperative Phase: Recognize Cues: Assessment  Age and general status of health  Review of systems  Medical and previous surgical history (including anesthesia history)  Malignant hyperthermia  Drug and substance use  Latex allergy  Blood donation considerations  During this time, discharge planning begins  Preoperative Phase: Physical Assessment/Signs & Symptoms Obtain baseline vital signs Assess: Cardiovascular Respiratory Kidney Neurologic Musculoskeletal Nutrition Skin Psychosocial INTRODUCTION TO PATHOPHYSIOLOGY IN PREOPERATIVE CARE  Understanding Pathophysiology in Preoperative Care Definition Pathophysiology is the study of how disease processes affect the function of the body. Essential for anticipating complications and planning care in the surgical setting. Importance in Preoperative Care Identifying and managing pre-existing conditions that could impact surgical outcomes. Understanding the body’s responses to stress, anesthesia, and surgery.  Key Considerations  Cardiovascular disease, diabetes, respiratory disorders, and other chronic conditions.  The impact of these conditions on perioperative risks and management strategies. PATHOPHYSIOLOGY OF CARDIOVASCULAR DISEASE IN SURGERY Cardiovascular Disease and Surgical Risk Increases the risk of bleeding and stroke during surgery. Hypertension: Management includes optimizing blood pressure preoperatively. Risk of myocardial infarction during surgery due to stress and anesthesia. Coronary Artery Disease: Preoperative evaluation includes EKG, stress tests, and possibly coronary angiography. Decreased cardiac output increases the risk of perioperative complications. Heart Failure: Management includes diuretics, beta-blockers, and careful fluid management. Pathophysiology of Diabetes in Surgery Diabetes and Surgical Outcomes Impairs wound healing and increases the risk of infection Hyperglycemia Preoperative management includes insulin adjustment and glucose monitoring. Risk due to fasting and insulin use; can cause intraoperative complications. Hypoglycemia Close monitoring of blood glucose levels is essential. Increases the risk of pressure ulcers and poor wound healing. Diabetic Neuropathy Careful positioning and monitoring of pressure points during surgery. Pathophysiology of Respiratory Disorders in Surgery  Respiratory Disorders and Surgical Risk  Chronic Obstructive Pulmonary Disease (COPD):  Increases the risk of postoperative respiratory failure and pneumonia.  Preoperative management includes optimizing pulmonary function with bronchodilators and corticosteroids.  Asthma:  Risk of bronchospasm during and after surgery.  Preoperative management includes assessing control of asthma and using preoperative bronchodilators.  Obstructive Sleep Apnea (OSA):  Increased risk of airway obstruction and hypoxia during anesthesia.  Management includes using CPAP machines preoperatively and careful airway management.  Preoperative Phase: Diagnostic Assessment CBC or hemoglobin level Urinalysis Blood type and screen and hematocrit Clotting studies (PT, Pregnancy test for Metabolic panel INR, aPTT) female patient CT or MRI (in Chest x-ray relationship to specific ECG surgery)  Preoperative Phase: Analyze Cues and Prioritize Hypotheses: Analysis  The priority collaborative problems for preoperative patients are  Need for health teaching due to unfamiliarity with surgical procedures and preparation  Anxiety due to fear of new or unknown experience, pain, and/or surgical outcomes  Preoperative Phase: Generate Solutions & Take Action: Planning and Implementation (1 of 2)  Need for Health Teaching  Provide information  Ensure informed consent is obtained  Ensure site marking  Implement dietary restrictions  Discuss scheduled drugs (reinforce surgeon’s or health care provider’s instructions)  Explain intestinal and skin preparation  Explain tubes, drains, vascular access  Teach methods to prevent respiratory and cardiovascular complications  Preoperative Phase: Generate Solutions & Take Action: Planning and Implementation (2 of 2)  Minimizing anxiety  Encourage communication  Promote rest  Use distraction  Teach the family or caregiver  Preoperative Electronic Health Record Review  Ensure all documentation, preoperative procedures, orders are complete  Check surgical consent form for signature  Confirm procedure is in agreement with consent form  Ensure site marking  Document allergies, height, and weight  Ensure all laboratory and diagnostic test results are in chart and abnormal results noted  Notify the surgical team of special needs, concerns, instructions  Preoperative Patient Preparation Remove Leave Ensure Apply Follow Remove most clothing; Leave valuables with family or Ensure patient is wearing ID Apply allergy band if indicated Follow agency policy provide gown caregiver, or lock up band regarding: Dentures Eyeglasses Prosthetic devices Fingernail polish or artificial nails  Preoperative Drugs Follow agency policy for administration, if ordered INTRODUCTION TO PHARMACOLOGY IN PREOPERATIVE CARE  Overview  Pharmacology plays a crucial role in the preoperative phase, where medication management can significantly impact surgical outcomes.  Key focus areas include managing existing chronic conditions, preparing the patient for anesthesia, and preventing potential complications.  Learning Objectives  Understand the role of pharmacology in optimizing patient safety and outcomes in the preoperative period.  Identify key medications commonly used in the preoperative phase and their implications for patient care.  Beta-Blockers Common Medications: Metoprolol (Lopressor) Atenolol (Tenormin) Propranolol (Inderal) Mechanism of Action: Beta-blockers work by blocking beta-adrenergic receptors in the heart, reducing heart rate and blood pressure, and decreasing myocardial oxygen demand. Indications: Continuation of beta-blockers in patients with hypertension, arrhythmias, or a history of myocardial infarction is crucial to prevent perioperative cardiac events. Nursing Considerations: Monitor: Vital signs, particularly heart rate and blood pressure, before administration. Hold Parameters: Typically hold if systolic BP < 100 mmHg or HR < 60 bpm  Anticoagulants Common Anticoagulants: Warfarin (Coumadin) Heparin Enoxaparin (Lovenox) Mechanism of Action: Anticoagulants inhibit clot formation by targeting different factors in the coagulation cascade. Preoperative Use: Indications: Used in patients with a history of thromboembolic events (e.g., DVT, PE) or atrial fibrillation. Nursing Considerations: Warfarin: May need to be discontinued 5-7 days before surgery; INR should be monitored. Heparin/Enoxaparin: Often used as bridging therapy if warfarin is stopped. Assess for bleeding risk: Monitor for signs of bleeding, and ensure reversal agents (e.g., Vitamin K for warfarin) are available if needed.  Insulin and Glycemic Control Types of Insulin: Rapid-Acting (e.g., Lispro, Aspart) Short-Acting (e.g., Regular Insulin) Long-Acting (e.g., Glargine, Detemir) Mechanism of Action: Insulin facilitates glucose uptake by cells, reducing blood glucose levels. Preoperative Use: Indications: Essential for managing blood glucose in diabetic patients, especially when fasting for surgery. Nursing Considerations: Adjust insulin dose: Fasting and surgery can cause fluctuations in blood glucose levels; dose adjustments may be necessary. Monitor blood glucose: Frequent monitoring is required to avoid hypo- or hyperglycemia. IV Insulin Protocols: May be initiated for tight glucose control, particularly in major surgeries.  Antibiotics for Surgical Prophylaxis Common Antibiotics: Cefazolin (Ancef) Vancomycin Metronidazole (Flagyl) Mechanism of Action: Antibiotics work by inhibiting bacterial cell wall synthesis (e.g., Cefazolin) or protein synthesis (e.g., Vancomycin), preventing bacterial growth and infection. Preoperative Use: Indications: Administered prophylactically to prevent surgical site infections, particularly in surgeries with a high risk of contamination. Timing: Typically given within 60 minutes before the surgical incision. Nursing Considerations: Cefazolin: First-line for most surgeries unless patient has a penicillin allergy. Vancomycin: Used for MRSA coverage or patients with a severe beta-lactam allergy. Monitor for allergic reactions: Especially in patients with known drug allergies.  Sedatives and Anxiolytics in Preoperative Care Common Medications: Midazolam (Versed) Lorazepam (Ativan) Diazepam (Valium) Mechanism of Action: These medications enhance the effect of the neurotransmitter GABA, promoting sedation, anxiolysis, and amnesia. Preoperative Use: Indications: Used to reduce preoperative anxiety and induce sedation. Nursing Considerations: Dosing: Careful dosing is essential to avoid excessive sedation, especially in elderly patients. Monitoring: Continuous monitoring of respiratory rate and oxygen saturation is required due to the risk of respiratory depression. Reversal Agent: Flumazenil should be available to reverse benzodiazepine effects if needed.  Antiemetics for Nausea and Vomiting Prevention Common Antiemetics: 5-HT3 receptor antagonists: Ondansetron (Zofran) Dopamine antagonists: Metoclopramide (Reglan) H1 antihistamines: Promethazine (Phenergan) Mechanism of Action: Antiemetics work by blocking receptors in the brain that trigger nausea and vomiting, such as serotonin (5-HT3) receptors or dopamine receptors. Preoperative Use: Indications: Prevent nausea and vomiting associated with anesthesia, particularly in high-risk patients. Nursing Considerations: Ondansetron: Preferred for its efficacy and lower side effect profile. Metoclopramide: Useful for patients with delayed gastric emptying. Promethazine: Effective but with a higher risk of sedation; use with caution. Monitor for side effects: Especially extrapyramidal symptoms with metoclopramide.  Reversal Agents and Emergency Medications Common Reversal Agents: Naloxone (Narcan) for opioid overdose. Flumazenil (Romazicon) for benzodiazepine overdose. Vitamin K for warfarin reversal. Mechanism of Action: Reversal agents work by competitively binding to receptors or antagonizing the effects of the primary medication. Preoperative Use: Indications: Used in emergencies where reversal of sedation, analgesia, or anticoagulation is required. Nursing Considerations: Naloxone: Rapid reversal of opioids can lead to acute withdrawal; titrate dose carefully. Flumazenil: Reverses sedation but monitor for seizures, especially in patients with benzodiazepine dependence. Vitamin K: Administered to reverse warfarin-induced anticoagulation; effects may be delayed. Patient Transfer to Surgical Suite Review and update Review and update EHR Reinforce Reinforce teaching Ensure Ensure patient is properly dressed Administer Administer any prescribed preoperative drugs  Preoperative Phase: Evaluate Outcomes: Evaluation  Expected outcomes  States understanding of informed consent and preoperative procedures  Demonstrates preoperative exercises and techniques to prevent complications  Verbalizes reduced anxiety Intraoperative Phase  Intraoperative Phase Overview: The intraoperative period is critical for ensuring patient safety and successful surgical outcomes. The nursing role in this phase involves close collaboration with the surgical team, monitoring patient status, and managing potential complications. Learning Objectives: Understand the roles of intraoperative personnel. Compare different types of anesthesia. Address nursing considerations specific to elderly patients during surgery.  Roles and Responsibilities of Intraoperative Personnel Surgical Team Members: Surgeon: Leads the surgical procedure; responsible for making incisions and performing surgery. Anesthesiologist/CRNA: Manages anesthesia and monitors the patient’s vital signs. Scrub Nurse: Maintains the sterile field, hands instruments to the surgeon. Circulating Nurse: Coordinates care, documents the procedure, manages non-sterile equipment. Surgical Technologist: Assists with equipment and supplies, supports the surgical team. Importance of Communication: Clear, concise communication is essential to prevent errors, manage complications, and ensure patient safety. Use of surgical checklists and time-outs to confirm patient identity, procedure, and site. Types of Anesthesia: Overview Anesthesia Categories: General Anesthesia Regional/Spinal Anesthesia Epidural Anesthesia Local Anesthesia Conscious Sedation Purpose of Anesthesia: To prevent pain and discomfort during surgery. To manage physiological responses to surgical stress.  Stages of General Anesthesia Stages of General Anesthesia: Stage I – Analgesia: Loss of pain sensation; patient remains conscious. Stage II – Excitement: Unconscious but may exhibit reflex movements; potential for erratic heart rate. Stage III – Surgical Anesthesia: Desired level for surgery; muscle relaxation, no pain or reflexes. Stage IV – Medullary Paralysis: Overdose stage; respiratory and cardiovascular collapse. Nursing Interventions: Induction: Ensure airway patency, monitor vital signs, prepare for potential complications. Emergence: Monitor for return of consciousness, manage airway, assess for pain and complications. Complications: Hypotension, respiratory depression, emergence delirium. Regional and Spinal Anesthesia Regional Anesthesia: Blocks sensation in a specific area of the body. Examples: Spinal, epidural, nerve blocks. Pharmacology: Common agents include lidocaine, bupivacaine. Spinal Anesthesia: Injection into the subarachnoid space, usually at the lumbar level. Advantages: Quick onset, effective for lower body procedures. Complications: Post-spinal headache, hypotension. Nursing Considerations: Before Administration: Assess patient’s coagulation status, ensure informed consent. During Procedure: Monitor for hypotension, support with fluids and vasopressors if needed.  Epidural and Local Anesthesia Epidural Anesthesia: Injection into the epidural space, typically used for labor or lower extremity surgeries. Advantages: Continuous infusion allows for prolonged analgesia. Complications: Dural puncture, infection, hypotension. Local Anesthesia: Examples: Lidocaine, bupivacaine for minor procedures. Mechanism: Blocks sodium channels, preventing nerve impulse transmission. Nursing Role: Monitor for allergic reactions, assess effectiveness.  Conscious Sedation PURPOSE: PROVIDES SEDATION WHILE MAINTAINING PATIENT RESPONSIVENESS. COMMON AGENTS: MIDAZOLAM, FENTANYL. NURSING RESPONSIBILITIES: MONITOR AIRWAY, ENSURE PATIENT COMFORT, ASSESS FOR SIDE EFFECTS LIKE HYPOTENSION OR RESPIRATORY DEPRESSION. ADVANTAGES: RAPID RECOVERY, MINIMAL IMPACT ON CONSCIOUSNESS. DISADVANTAGES: RISK OF OVER-SEDATION, REQUIRES CONTINUOUS MONITORING.  Complications of Anesthesia and Nursing Interventions Malignant Hyperthermia: Pathophysiology: Genetic disorder triggered by certain anesthetics, leading to uncontrolled calcium release in muscles. Interventions: Immediate administration of dantrolene, cooling measures, monitoring for hyperkalemia. Hypotension: Pathophysiology: Vasodilation from anesthetics leads to decreased blood pressure. Interventions: Fluid resuscitation, vasopressors, monitor vitals. Post-Spinal Headache: Pathophysiology: Leakage of cerebrospinal fluid from the puncture site. Interventions: Hydration, caffeine, blood patch if severe. Inadvertent Hypothermia: Pathophysiology: Loss of body heat during surgery. Interventions: Warm blankets, forced-air warming devices, monitoring core temperature. Latex Allergy: Pathophysiology: Immune response to latex proteins, can cause anaphylaxis. Interventions: Use latex-free products, have emergency equipment ready.  Nursing Care for Elderly Patients During Surgery Content: Physiological Changes: Decreased cardiovascular and pulmonary reserve. Increased risk for skin breakdown and pressure ulcers. Nursing Considerations: Positioning: Use extra padding, reposition frequently to prevent pressure injuries. Temperature Regulation: Monitor closely for hypothermia. Medication Sensitivity: Adjust dosages, monitor for prolonged drug effects. Communication: Ensure clear, simple explanations to reduce anxiety.  Positioning and Preventing Injury in the OR Common Positions: Supine: Most common; used for abdominal, thoracic surgeries. Lithotomy: Used for gynecological procedures. Prone: Used for spinal surgeries. Nursing Responsibilities: Ensure proper alignment to avoid nerve damage. Use pressure-reducing devices to prevent skin breakdown. Monitor for signs of compartment syndrome in limbs. Injury Prevention: Electrical Hazards: Ensure proper grounding of all equipment. Foreign Object Retention: Perform surgical counts before and after the procedure. Wound Infection: Maintain sterile field, administer prophylactic antibiotics.  Surgical Skin Closures and Drains Skin Closures: Sutures: Most common; provides strong wound closure. Staples: Used for larger incisions; faster to apply but can cause more scarring. Surgical Drains: Jackson-Pratt (JP) Drain: Closed-suction device to remove fluid. Hemovac: Similar to JP drain but larger; used for larger fluid volumes. Nursing Care: Monitor for signs of infection at closure sites. Ensure drains are functioning properly, measure and record output. Educate patients on care of incisions and drains post-discharge. POSTOPERATIVE PHASE  Postoperative Phase (1 of 2)  Begins with completion of surgical procedure and transfer to PACU or ICU  Phases  Phase I  Phase II  Phase III  Postoperative Phase (2 of 2)  PACU nurse  Skilled in care of patients with multiple problems immediately after surgery  Has ACLS training  Makes knowledgeable, critical decisions if needed  Facilitates discharge (if ambulatory care) or hands off to nurse generalist  Postoperative Phase: Recognize Cues: Assessment  History  Review preoperative assessment  Identify potential surgical complications  Respiratory System  Assess for patent airway, adequate gas exchange  Note artificial airway, if applicable  Check oxygen delivery device, if applicable  Check lungs every 4 hours for first 24 hours following surgery (more frequently if needed); then follow agency policy  Cardiovascular System  Assess vitals and compare with baseline  Report BP changes that at 25% higher or lower than baseline  Cardiac monitoring may be ordered  Perform peripheral vascular assessment daily  Apply antiembolism stockings and pneumatic compression devices if ordered; administer prophylactic drugs if ordered Sequential Compression Devices (SCDs)  Neurologic System  Assess  Cerebral function and level of consciousness  Orientation to person, place, time, and situation  Prevent postoperative delirium  Motor and sensory function (after general anesthesia) Range of Motion (ROMs)  Fluid, Electrolyte, and Acid–Base balance  Assess  Intake and output (I&O)  Hydration status  IV fluids  Acid–base balance Nasogastric (NG) tube drainage  Kidney/Urinary System  Assess  Return of urination  Effects of drugs on urination  Signs of urine retention  Report urine output of