Intro to Med Surg Exam 1 Powerpoints PDF

Chapter 10 Fluid and Electrolytes Fluid and Electrolyte Balance Necessary for life, homeostasis (internal equilibrium) Nursing role: anticipate, identify, and respond to possible imbalances Copyright © 2022 Wolters Kluwer · All Rights Reserved Fluid Approximately 60% of...

Chapter 10 Fluid and Electrolytes Fluid and Electrolyte Balance Necessary for life, homeostasis (internal equilibrium) Nursing role: anticipate, identify, and respond to possible imbalances Copyright © 2022 Wolters Kluwer · All Rights Reserved Fluid Approximately 60% of typical adult is fluid (water and electrolytes) o Varies with age, body fat, gender Intracellular fluid (fluid in cells) Loading… o 2/3 of body fluid, skeletal muscle mass Extracellular fluid (fluid outside the cells) o Intravascular (fluid within blood vessels): plasma, erythrocytes, leukocytes, thrombocytes o Interstitial (fluid that surrounds the cell): lymph o Transcellular: cerebrospinal, pericardial, synovial Copyright © 2022 Wolters Kluwer · All Rights Reserved Electrolytes Active chemicals that carry positive (cations) and negative (anions) electrical charges o Major cations: sodium, potassium, calcium, magnesium, hydrogen ions o Major anions: chloride, bicarbonate, phosphate, sulfate, negatively charged protein ions o Expressed in terms of millequivalents (mEq) per liter Electrolyte concentrations differ in ICF and ECF compartments Copyright © 2022 Wolters Kluwer · All Rights Reserved Regulation of Fluid #1 Osmosis—the diffusion of water caused by fluid and solute concentration gradients Movement of fluid through capillary walls depends on Loading… o Hydrostatic pressure: exerted on walls of blood vessels o Osmotic pressure: exerted by protein in plasma Direction of fluid movement depends on differences of hydrostatic pressure and osmotic pressure Copyright © 2022 Wolters Kluwer · All Rights Reserved Regulation of Fluid #2 Osmosis: area of low solute concentration to area of high solute concentration Diffusion: solutes move from area of higher concentration to one of lower concentration Filtration: movement of water, solutes occurs from area of high hydrostatic pressure to area of low hydrostatic pressure Active transport: Sodium–potassium pump o Maintains higher concentration of extracellular sodium, intracellular potassium Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #1 Is the following statement true or false? Diffusion is the process by which solutes move from an area of higher concentration to one of lower concentration and requires energy. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #1 False Rationale: Although diffusion occurs when fluid moves from an area of higher to lower concentration, this process does not require an expenditure of energy. Copyright © 2022 Wolters Kluwer · All Rights Reserved Gains and Losses of Fluid and Electrolytes Gain o Healthy people gain fluids by drinking and eating o Daily I&O of water are equal Loss o Kidney: urine output of 1mL/kg/hr o Skin loss: sensible due to sweating and insensible due to fever, exercise, and burns o Lungs: 300 mL everyday, greater with increased respirations o GI tract: large losses due to diarrhea and fistulas Copyright © 2022 Wolters Kluwer · All Rights Reserved  Homeostatic Mechanisms Maintain body fluid within normal limits (Refer to Figures 10-5 and 10-6) o Kidney o Renin– o Heart and Blood Angiotensin– Vessels Aldosterone System o Lung o Antidiuretic o Pituitary Hormone o Adrenal o Osmoreceptors o Parathyroid o Natriuretic o Baroreceptors Peptides Copyright © 2022 Wolters Kluwer · All Rights Reserved Gerontologic Considerations Clinical manifestations of imbalance may be subtle Fluid deficit may cause delirium Decreased cardiac reserve Reduced renal function Loading… Dehydration is common Age-related thinning of the skin and loss of strength and elasticity Copyright © 2022 Wolters Kluwer · All Rights Reserved Fluid Volume Disturbances Fluid volume deficit (FVD): hypovolemia Fluid volume excess (FVE): hypervolemia Copyright © 2022 Wolters Kluwer · All Rights Reserved Fluid Volume Deficit (Hypovolemia) May occur alone or in combination with other imbalances Loss of extracellular fluid exceeds intake ratio of water o Electrolytes lost in same proportion as they exist in normal body fluids Dehydration o Not the same as FVD o Loss of water alone, with increased serum sodium levels Copyright © 2022 Wolters Kluwer · All Rights Reserved Causes of FVD Abnormal fluid losses o Vomiting, diarrhea, sweating, GI suctioning Decreased intake o Nausea, lack of access to fluids Third-space fluid shifts o Due to burns, ascites Additional causes o Diabetes insipidus, adrenal insufficiency, hemorrhage Copyright © 2022 Wolters Kluwer · All Rights Reserved Clinical Manifestations, Assessment and Diagnostic Findings of FVD Can develop rapidly Severity depends on degree of loss See Table 10-4 for clinical signs and symptoms and laboratory findings Copyright © 2022 Wolters Kluwer · All Rights Reserved Gerontologic Considerations for FVD Assessment o Cognition o Ambulation o ADLs o Gag Reflex Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical Management of FVD Oral route is preferred IV for acute or severe losses Types of Solutions o Isotonic o Hypotonic o Hypertonic o Colloid o Refer to Table 10-5 Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #2 Is the following statement true or false? An isotonic solution, such as 0.9% NaCl (Normal Saline), is the only intravenous solution that may be administered with blood products. Copyright © 2022 Wolters Kluwer · All Rights Reserved  Chapter 14 Preoperative Nursing Management Perioperative Nursing Preoperative phase: begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the operating room (OR) bed Intraoperative phase: begins when the patient is transferred onto the OR bed and ends with admission to the PACU (postanesthesia care unit) Postoperative phase: begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home Copyright © 2022 Wolters Kluwer · All Rights Reserved Surgical Classification Facilitating a diagnosis, a cure, or repair Reconstructive, cosmetic, or palliative Rehabilitative Based upon the degree of urgency involved: Loading… emergent, urgent, required, elective, and optional Copyright © 2022 Wolters Kluwer · All Rights Reserved Preadmission Testing Initiates the nursing assessment process Admission data: demographics, health history, other information pertinent to the surgical procedure Verifies completion of preoperative diagnostic testing according to patient’s needs Begins discharge planning by assessing patient’s need for postoperative transportation and care Copyright © 2022 Wolters Kluwer · All Rights Reserved Preoperative Assessment #1 Health history and physical exam Medications and allergies Nutritional, fluid status Dentition Loading… Drug or alcohol use Respiratory and cardiovascular status Hepatic, renal function Copyright © 2022 Wolters Kluwer · All Rights Reserved Preoperative Assessment #2 Endocrine function Immune function Previous medication use Psychosocial factors Spiritual, cultural beliefs Copyright © 2022 Wolters Kluwer · All Rights Reserved Medications That Potentially Affect Surgical Experience Corticosteroids Anticoagulants Diuretics Anticonvulsant medications Phenothiazines Thyroid hormone Tranquilizers Opioids Insulin Over-the-counter and Antibiotics herbals Copyright © 2022 Wolters Kluwer · All Rights Reserved  Question #1 Which medication classification must be assessed during the preoperative period because it can cause an electrolyte imbalance during surgery? A. Corticosteroids B. Diuretics C. Phenothiazines D. Insulin Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #1 B. Diuretics Rationale: Diuretics during anesthesia may cause excessive respiratory depression resulting from an associated electrolyte imbalance. Corticosteroids can cause cardiovascular collapse if discontinued suddenly. Phenothiazines may increase the hypotensive action of anesthetics. Interaction between anesthetics and insulin must be considered when a patient with diabetes mellitus undergoes surgery. Copyright © 2022 Wolters Kluwer · All Rights Reserved Gerontologic Considerations Cardiac reserves are lower Renal and hepatic functions are depressed Gastrointestinal activity is likely to be reduced Respiratory compromise Decreased subcutaneous fat; more susceptible to temperature changes May need more time and multiple education formats to understand and retain what is communicated Copyright © 2022 Wolters Kluwer · All Rights Reserved Special Considerations During Preoperative Period Patients with obesity Patients with disabilities Patients undergoing ambulatory surgery Patients undergoing emergency surgery Loading… Copyright © 2022 Wolters Kluwer · All Rights Reserved Informed Consent Should be in writing before nonemergent surgery Legal mandate Surgeon must explain the procedure, benefits, risks, complications, etc. Nurse clarifies information and witnesses signature Consent is valid ONLY when signed before administering psychoactive premedication Consent accompanies patient to OR Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #2 Is the following statement true or false? Voluntary and written informed consent from the patient is necessary before nonemergent surgery can be performed solely to protect the surgeon from claims of an unauthorized operation or battery. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #2 False Rationale: Voluntary and written informed consent from the patient is necessary before nonemergent surgery can be performed to protect the patient from unsanctioned surgery and protect the surgeon from claims of an unauthorized operation or battery. Consent is a legal mandate, but it also helps the patient to prepare psychologically, because it helps to ensure that the patient understands the surgery to be performed. Copyright © 2022 Wolters Kluwer · All Rights Reserved Patient Education Deep breathing, coughing, incentive spirometry Mobility, active body movement Pain management Cognitive coping strategies Instruction for patients undergoing ambulatory surgery Copyright © 2022 Wolters Kluwer · All Rights Reserved Immediate Preoperative Nursing Interventions Patient changes into gown, hair covered, mouth inspected, jewelry removed, valuables stored in a secure place Administering preanesthetic medication Maintaining preoperative record Transporting patient to presurgical area Attending to family needs Copyright © 2022 Wolters Kluwer · All Rights Reserved General Preoperative Nursing Interventions Providing psychosocial interventions o Reducing anxiety, decreasing fear o Respecting cultural, spiritual, religious beliefs Maintaining patient safety Managing nutrition, fluids Preparing bowel Preparing skin Copyright © 2022 Wolters Kluwer · All Rights Reserved  Question #3 The nurse is preparing to administer a premedication. Which of the following actions should the nurse take first? A. Have the family present B. Ensure that the preoperative shave is completed C. Have the patient void D. Make sure the patient is covered with a warm blanket Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #3 C. Have the patient void Rationale: Having the patient void prior to administering a premedication is necessary for patient safety to prevent falls and injury. Shaving is no longer recommended; clipping the hair is evidence-based practice. The family can be present, and a warm blanket can be provided any time patient appears cold or asks for it, but the patient fall risk is greatly increased after receiving preoperative medications that are sedative or amnesic. Copyright © 2022 Wolters Kluwer · All Rights Reserved Expected Outcomes Relief of anxiety Decreased fear Understanding of the surgical intervention No evidence of preoperative complications Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #2 True Rationale: Tonicity is the tension that osmotic pressure of a solution with impermeable solutes exerts on cell size because of water movement across the cell membrane. Normal saline has nearly the same tonicity as plasma. Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Management of FVD I&O at least every 8 hours, sometimes hourly Daily weight Vital signs closely monitored Skin and tongue turgor, mucosa, urine output, mental status Measures to minimize fluid loss Administration of oral fluids Administration of parenteral fluids Copyright © 2022 Wolters Kluwer · All Rights Reserved Fluid Volume Excess (Hypervolemia) Expansion of the ECF caused by the abnormal retention of water and sodium in approximately the same proportions in which they normally exist in the ECF Secondary to an increase in the total-body sodium content Copyright © 2022 Wolters Kluwer · All Rights Reserved Causes of FVE Due to fluid overload or diminished homeostatic mechanisms Heart failure, kidney injury, cirrhosis of liver Contributing factors: Consumption of excessive amounts of table salt or other sodium salts Excessive administration of sodium-containing fluids Copyright © 2022 Wolters Kluwer · All Rights Reserved Clinical Manifestations, Assessment and Diagnostic Findings of FVE Edema Distended neck veins Crackles BUN HCT See Table 10-4 for signs and symptoms and laboratory findings Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical Management of FVE Pharmacologic o Diuretics Dialysis Nutritional o Dietary restrictions of sodium Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Management of FVE I&O and daily weights; assess lung sounds, edema, other symptoms Monitor responses to medications—diuretics and parenteral fluids Promote adherence to fluid restrictions, patient teaching related to sodium and fluid restrictions Monitor, avoid sources of excessive sodium, including medications Promote rest Copyright © 2022 Wolters Kluwer · All Rights Reserved Electrolyte Imbalances Sodium: hyponatremia, hypernatremia Potassium: hypokalemia, hyperkalemia Calcium: hypocalcemia, hypercalcemia Magnesium: hypomagnesemia, hypermagnesemia Phosphorus: hypophosphatemia, hyperphosphatemia Chloride: hypochloremia, hyperchloremia Copyright © 2022 Wolters Kluwer · All Rights Reserved Hyponatremia Serum sodium less than 135 mEq/L Acute o Result of fluid overload of a surgical patient Chronic o Seen outside of hospital setting, longer duration, less serious neurologic sequelae Exercise associated o More common in women of small stature, extreme temperatures, excessive fluid intake, prolonged exercise Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology, Clinical Manifestations, Assessment and Diagnostic Findings #1 Hyponatremia o Pathophysiology: Imbalance of water, losses by vomiting, diarrhea, sweating, diuretics, adrenal insufficiency, certain medications, SIADH o Clinical manifestations: poor skin turgor, dry mucosa, headache, decreased salivation, decreased blood pressure, nausea, abdominal cramping, neurologic changes o Serum sodium levels o Refer to Table 10-6 Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical and Nursing Management of Hyponatremia Treat underlying condition Sodium replacement Water restriction Medication Loading… Assessment: I&O, daily weight, lab values, CNS changes Encourage dietary sodium Monitor fluid intake Effects of medications (diuretics, lithium) Copyright © 2022 Wolters Kluwer · All Rights Reserved Hypernatremia Serum sodium greater than 145 mEq/L Occurs in patients with normal fluid volume, FVD, FVE Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology, Clinical Manifestations, Assessment and Diagnostic Findings Hypernatremia o Pathophysiology: fluid deprivation, excess sodium administration, diabetes insipidus, heat stroke, hypertonic IV solutions o Clinical manifestations: thirst; elevated temperature o Serum osmolality greater than 300 mOsm/kg o Increased urine specific gravity and osmolality Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical and Nursing Management of Hypernatremia Gradual lowering of serum sodium level via infusion of hypotonic electrolyte solution Diuretics Assessment for abnormal loss of water and low water intake Assess for over-the-counter sources of sodium Monitor for CNS changes Copyright © 2022 Wolters Kluwer · All Rights Reserved Hypokalemia Below-normal serum potassium Less than 3.5 mEq/L May occur with normal potassium levels: when alkalosis is present a temporary shift of serum potassium into cells occurs Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology, Clinical Manifestations, Assessment and Diagnostic Findings #2 Hypokalemia o Pathophysiology: GI losses, medications, prolonged intestinal suctioning, recent ileostomy, tumor of the intestine, alterations of acid–base balance, poor dietary intake, hyperaldosteronism o Clinical manifestations: ECG changes, dysrhythmias, dilute urine, excessive thirst, fatigue, anorexia, muscle weakness, decreased bowel motility, paresthesia o ECG changes o Refer to Table 10-7 Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical and Nursing Management of Hypokalemia Potassium replacement: Increased dietary potassium, oral potassium supplements or IV potassium for severe deficit (unless oliguria present) Monitor ECG for changes Monitor ABGs Monitor patients receiving digitalis for toxicity Monitor for early signs and symptoms Administer IV potassium only after adequate urine output has been established Copyright © 2022 Wolters Kluwer · All Rights Reserved Hyperkalemia Serum potassium greater than 5.0 mEq/L Seldom occurs in patients with normal renal function Increased risk in older adults Cardiac arrest is frequently associated Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology, Clinical Manifestations, Assessment and Diagnostic Findings #3 Hyperkalemia o Pathophysiology: Impaired renal function, rapid administration of potassium, hypoaldosteronism, medications, tissue trauma, acidosis o Clinical manifestations: Cardiac changes and dysrhythmias, muscle weakness, paresthesias, anxiety, GI manifestations o ECG changes o Metabolic or respiratory acidosis o Refer to Table 10-7 Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical and Nursing Management of Hyperkalemia Monitor ECG, heart rate (apical pulse) and blood pressure, assess labs, monitor I&O, obtain apical pulse Limitation of dietary potassium and dietary teaching Administration of cation exchange resins (sodium polystyrene sulfonate) Emergent care: IV calcium gluconate, IV sodium bicarbonate, IV regular insulin and hypertonic dextrose IV, beta-2 agonists, dialysis Administer IV slowly and with an infusion pump Copyright © 2022 Wolters Kluwer · All Rights Reserved Hypocalcemia Serum level less than 8.6 mg/dL, must be considered in conjunction with serum albumin level Serum calcium level controlled by parathyroid hormone and calcitonin Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology, Clinical Manifestations, Assessment and Diagnostic Findings #4 Hypocalcemia o Pathophysiology: hypoparathyroidism, malabsorption, osteoporosis, pancreatitis, alkalosis, transfusion of citrated blood, kidney injury, medications o Clinical manifestations: tetany, circumoral numbness, paresthesias, hyperactive DTRs, Trousseau sign, Chvostek sign, seizures, respiratory symptoms of dyspnea and laryngospasm, abnormal clotting, anxiety o Ionized calcium levels o Refer to Table 10-8 Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical and Nursing Management of Hypocalcemia IV of calcium gluconate for emergent situations (monitor for risk of extravasation) Seizure precautions Oral calcium and vitamin D supplements Exercises to decrease bone calcium loss Patient teaching related to diet and medications Copyright © 2022 Wolters Kluwer · All Rights Reserved Hypercalcemia Serum level greater than 10.4 mg/dL Mild and moderate hypercalcemia usually asymptomatic. Hypercalcemia crisis has high mortality Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology, Clinical Manifestations, Assessment and Diagnostic Findings #5 Hypercalcemia o Pathophysiology: malignancy and hyperparathyroidism, bone loss related to immobility, diuretics o Clinical manifestations: polyuria, thirst, muscle weakness, intractable nausea, abdominal cramps, severe constipation, diarrhea, peptic ulcer, bone pain, ECG changes, dysrhythmias o Refer to Table 10-8 Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical and Nursing Management of Hypercalcemia Treat underlying cause (Cancer) Administer IV fluids, furosemide, phosphates, calcitonin, bisphosphonates Increase mobility Encourage fluids Dietary teaching, fiber for constipation Ensure safety Copyright © 2022 Wolters Kluwer · All Rights Reserved Hypomagnesemia Serum level less than 1.8 mg/dL Associated with hypokalemia and hypocalcemia Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology, Clinical Manifestations, Assessment and Diagnostic Findings #6 Hypomagnesemia o Pathophysiology: alcoholism, GI losses, enteral or parenteral feeding deficient in magnesium, medications, rapid administration of citrated blood o Clinical manifestations: Chvostek and Trousseau signs, apathy, depressed mood, psychosis, neuromuscular irritability, ataxia, insomnia, confusion, muscle weakness, tremors, ECG changes and dysrhythmias o Ionized serum magnesium level o Refer to Table 10-9 Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical and Nursing Management of Hypomagnesemia Magnesium sulfate IV is administered with an infusion pump; monitor vital signs and urine output Calcium gluconate or hypocalcemic tetany or hypermagnesemia Oral magnesium Monitor for dysphagia Seizure precautions Dietary teaching (green, leafy vegetables; beans, lentils, almonds, peanut butter) Copyright © 2022 Wolters Kluwer · All Rights Reserved Hypermagnesemia Serum level greater than 2.6 mg/dL Rare electrolyte abnormality, because the kidneys efficiently excrete magnesium Falsely elevated levels with a hemolyzed blood sample Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology, Clinical Manifestations, Assessment and Diagnostic Findings #7 Hypermagnesemia o Pathophysiology: kidney injury, diabetic ketoacidosis, excessive administration of magnesium, extensive soft tissue injury o Clinical manifestations: hypoactive reflexes, drowsiness, muscle weakness, depressed respirations, ECG changes, dysrhythmias, and cardiac arrest o Refer to Table 10-9 Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical and Nursing Management of Hypermagnesemia IV calcium gluconate Ventilatory support for respiratory depression Hemodialysis Administration of loop diuretics, sodium chloride, and LR Avoid medications containing magnesium Patient teaching regarding magnesium-containing over-the-counter medications Observe for DTRs and changes in LOC Copyright © 2022 Wolters Kluwer · All Rights Reserved Hypophosphatemia Serum level below 2.7 mg/dL Hypophosphatemia can occur when total-body phosphorus stores area normal Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology, Clinical Manifestations, Assessment and Diagnostic Findings #8 Hypophosphatemia o Pathophysiology: alcoholism, refeeding of patients after starvation, pain, heat stroke, respiratory alkalosis, hyperventilation, diabetic ketoacidosis, hepatic encephalopathy, major burns, hyperparathyroidism, low magnesium, low potassium, diarrhea, vitamin D deficiency, use of diuretic and antacids o Clinical manifestations: neurologic symptoms, confusion, muscle weakness, tissue hypoxia, muscle and bone pain, increased susceptibility to infection o 24-hour urine collection o Elevated PTH levels o Refer to Table 10-10 Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical and Nursing Management of Hypophosphatemia Prevention is the goal Oral or IV phosphorus replacement (only for patients with serum phosphorus levels less than 1 mg/dL not to exceed 3 mmol/hr), Burosumab, correct underlying cause Monitor IV site for extravasation Monitor phosphorus, vitamin D and calcium levels Encourage foods high in phosphorus (milk, organ meats, beans nuts, fish, poultry), gradually introduce calories for malnourished patients receiving parenteral nutrition Copyright © 2022 Wolters Kluwer · All Rights Reserved Hyperphosphatemia Serum level above 4.5 mg/dL Can occur with increased intake, decreased excretion, or shifting of phosphate from intracellular to extracellular spaces Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology, Clinical Manifestations, Assessment and Diagnostic Findings #9 Hyperphosphatemia o Pathophysiology: kidney injury, excess phosphorus, excess vitamin D, acidosis, hypoparathyroidism, chemotherapy o Clinical manifestations: few symptoms; soft tissue calcifications, symptoms occur due to associated hypocalcemia o X-rays show abnormal bone development o Decreased PTH levels o BUN o Creatinine o Refer to Table 10-10 Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical and Nursing Management of Hyperphosphatemia Treat underlying disorder Vitamin D preparations, calcium-binding antacids, phosphate-binding gels or antacids, loop diuretics, IV fluids (Normal Saline), dialysis Monitor phosphorus and calcium levels Avoid high-phosphorus foods Patient teaching related to diet, phosphate- containing substances, signs of hypocalcemia Copyright © 2022 Wolters Kluwer · All Rights Reserved Hypochloremia Serum level less than 97 mEq/L Aldosterone impacts reabsorption Bicarbonate has an inverse relationship with chloride Chloride mainly obtained from the diet Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology, Clinical Manifestations, Assessment and Diagnostic Findings #10 Hypochloremia o Pathophysiology: Addison disease, reduced chloride intake, GI loss, diabetic ketoacidosis, excessive sweating, fever, burns, medications, metabolic alkalosis o Loss of chloride occurs with loss of other electrolytes, potassium, sodium o Clinical manifestations: agitation, irritability, weakness, hyperexcitability of muscles, dysrhythmias, seizures, coma o ABG o Refer to Table 10-11 Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical and Nursing Management of Hypochloremia Replace chloride-IV NS or 0.45% NS Ammonium chloride Monitor I&O, ABG values and electrolyte levels Assess for changes in LOC Educate about foods high in chloride (tomato juice, bananas, eggs, cheese, milk) and avoid drinking free water (water without electrolytes) Copyright © 2022 Wolters Kluwer · All Rights Reserved Hyperchloremia Serum level more than 107 mEq/L Hypernatremia, bicarbonate loss, and metabolic acidosis can occur Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology, Clinical Manifestations, Assessment and Diagnostic Findings #11 Hyperchloremia o Pathophysiology: usually due to iatrogenically induced hyperchloremic metabolic acidosis o Clinical manifestations: tachypnea; lethargy; weakness; rapid, deep respirations; hypertension; cognitive changes o Normal serum anion gap o Potassium Levels o ABGs o Urine Chloride Level o Refer to Table 10-11 Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical and Nursing Management of Hyperchloremia Correct the underlying cause and restore electrolyte and fluid balance Hypertonic IV solutions Lactated Ringers Sodium bicarbonate, diuretics Monitor I&O, ABG Focused assessments of respiratory, neurologic, and cardiac systems Patient teaching related to diet and hydration Copyright © 2022 Wolters Kluwer · All Rights Reserved Maintaining Acid–Base Balance Normal plasma pH 7.35 to 7.45: hydrogen ion concentration Major extracellular fluid buffer system; bicarbonate–carbonic acid buffer system Kidneys regulate bicarbonate in ECF Lungs, under control of medulla, regulate CO2, and thus the carbonic acid in ECF Refer to Table 10-12 Other buffer systems o ECF: inorganic phosphates, plasma proteins o ICF: proteins, organic, inorganic phosphates o Hemoglobin Copyright © 2022 Wolters Kluwer · All Rights Reserved Acute and Chronic Metabolic Acidosis Low pH 26 mEq/L Hypokalemia will produce alkalosis Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology, Clinical Manifestations, Assessment and Diagnostic Findings #13 Metabolic Alkalosis o Pathophysiology: Most commonly due to vomiting or gastric suction, may also be due to medications, especially long-term diuretic use, hyperaldosteronism, Cushing’s syndrome, and hypokalemia will produce alkalosis o Clinical manifestations: symptoms related to decreased calcium, respiratory depression, tachycardia, symptoms of hypokalemia including tingling of toes, fingers, dizziness and tetany, ECG changes, decreased GI motility o Urine chloride levels o Refer to Table 10-13 Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical and Nursing Management of Metabolic Alkalosis Correct the underlying acid–base disorder Restore fluid volume with sodium chloride solutions Monitor I&O Monitor for ECG and neurologic changes Copyright © 2022 Wolters Kluwer · All Rights Reserved Acute and Chronic Respiratory Acidosis Low pH 42 mm Hg Always due to respiratory problem with inadequate ventilation, resulting in elevated plasma levels of CO2 Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology, Clinical Manifestations, Assessment and Diagnostic Findings #14 Respiratory Acidosis o Pathophysiology: Pulmonary edema, overdose, atelectasis, pneumothorax, severe obesity, pneumonia, COPD, muscular dystrophy, multiple sclerosis, myasthenia gravis o Clinical Manifestations: With chronic respiratory acidosis, body may compensate, may be asymptomatic. With acute respiratory acidosis may see sudden increased pulse, respiratory rate, and BP; mental changes; feeling of fullness in head (intracranial pressure), and increased conjunctival vessels. o Refer to Table 10-13 Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical and Nursing Management of Respiratory Acidosis Improve ventilation Bronchodilators, antibiotics, anticoagulants Pulmonary physiotherapy Adequate hydration Mechanical ventilation if necessary Monitor respiratory status, I&O Copyright © 2022 Wolters Kluwer · All Rights Reserved Acute and Chronic Respiratory Alkalosis High pH >7.45 PaCO2 94% Base excess/deficit ±2 mEq/L Refer to Chart 10-3 Copyright © 2022 Wolters Kluwer · All Rights Reserved  Question #3 Which is the correct interpretation of this arterial blood gas (ABG)? pH = 7.5 PaCO2 = 37 HCO3 = 30 A. Respiratory Acidosis B. Respiratory Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #3 D. Metabolic Alkalosis Rationale: The pH is above the normal range indicating alkalosis. The CO2 is within normal range indicating no respiratory involvement. The HCO3 is above normal range indicating alkalosis. When the body absorbs too much bicarbonate, this creates a metabolic imbalance. Copyright © 2022 Wolters Kluwer · All Rights Reserved  Chapter 15 Intraoperative Nursing Management Members of the Surgical Team Patient Anesthesiologist (physician) or certified registered nurse anesthetist (CRNA) Surgeon Nurses Surgical technicians Registered nurse first assistants (RNFAs) or certified surgical technologists (assistants) Copyright © 2022 Wolters Kluwer · All Rights Reserved Surgical Team Roles Circulating nurse Scrub role Surgeon Registered nurse first assistant Loading… Anesthesiologist, anesthetist Note: role of nurse as patient advocate Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #1 Is the following statement true or false? The circulating nurse is responsible for monitoring the surgical team. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #1 True Rationale: The circulating nurse manages the OR and protects the patient’s safety and health by monitoring the activities of the surgical team, checking the OR conditions, and continually assessing the patient for Loading… signs of injury and implementing appropriate interventions. Copyright © 2022 Wolters Kluwer · All Rights Reserved Intraoperative Complications Anesthesia awareness Nausea, vomiting Anaphylaxis Hypoxia, respiratory complications Hypothermia Malignant hyperthermia Infection Copyright © 2022 Wolters Kluwer · All Rights Reserved Adverse Effects of Surgery and Anesthesia Allergic reactions, drug toxicity or reactions Cardiac dysrhythmias CNS changes, oversedation, undersedation Trauma: laryngeal, oral, nerve, skin, including burns Hypotension Thrombosis Refer to Chart 15-2 Copyright © 2022 Wolters Kluwer · All Rights Reserved Gerontologic Considerations Older adult patients are at higher risk for complications from anesthesia and surgery compared to younger adult patients due to several factors: o Age-related cardiovascular and pulmonary changes o Decreased tissue elasticity (lung and cardiovascular systems) and reduced lean tissue mass o Decreases the rate at which the liver can inactivate many anesthetic agents o Decreased kidney function slows the elimination of waste products and anesthetic agents o Impaired ability to increase metabolic rate and impaired thermoregulatory mechanisms Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #2 Is the following statement true or false? The most frequent early sign for a patient at risk for malignant hyperthermia subsequent to general anesthesia is bradycardia. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #2 False Rationale: The most frequent early sign for a patient at risk for malignant hyperthermia subsequent to general anesthesia is tachycardia. Copyright © 2022 Wolters Kluwer · All Rights Reserved Prevention of Infection Surgical environment o Unrestricted zone: street clothes allowed o Semirestricted zone: scrub clothes and caps o Restricted zone: scrub clothes, shoe covers, Loading… caps, and masks Surgical asepsis Environmental controls Refer to Figure 15-3 Copyright © 2022 Wolters Kluwer · All Rights Reserved Basic Guidelines for Surgical Asepsis All materials in contact with the surgical wound or used within the sterile field must be sterile Gowns considered sterile in front from chest to level of sterile field, sleeves from 2 inches above elbow to cuff Sterile drapes are used to create a sterile field. Only top of draped tables are considered sterile Items dispensed by methods to preserve sterility Movements of surgical team are from sterile to sterile, from unsterile to unsterile only Copyright © 2022 Wolters Kluwer · All Rights Reserved Guidelines for Surgical Asepsis Movement at least 1-foot distance from sterile field must be maintained When sterile barrier is breached, area is considered contaminated Every sterile field is constantly maintained, monitored o Items of doubtful sterility considered unsterile Sterile fields prepared as close to time of use The routine administration of hyperoxia (high levels of oxygen) is not recommended to reduce surgical site infections Copyright © 2022 Wolters Kluwer · All Rights Reserved Comparison of Anesthetic Agents and Delivery Systems General Inhalation: Refer to Table 15-1; Figure 15-4 (A, B, C) Given simaltaniously w/IV Intravenous: Refer to Table 15-2 Regional: Refer to Table 15-3 Patient awake - labor -Pain control in Epidural: Refer to Figure 15-5 -BlocksSensor aback , Spinal: Refer to Figure 15-5 GiveIt's headaches Sedation/ moderate doses Smaller local anesthetic *conscious Sedation - Kiddo in MRI Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Process: Interventions Reducing anxiety Reducing latex exposure Preventing perioperative positioning injury Protecting patient from injury Serving as patient advocate Monitoring, managing potential complications will be it's you advocate Copyright © 2022 Wolters Kluwer · All Rights Reserved Positioning Factors to Consider Patient should be as comfortable as possible Operative field must be adequately exposed Position must not obstruct/compress respirations, vascular supply, or nerves Extra safety precautions for older adults, patients who are thin or obese, and anyone with a physical deformity Eight need more space Light restraint before induction in case of excitement Copyright © 2022 Wolters Kluwer · All Rights Reserved Laparotomy Position, Trendelenburg Position, Lithotomy Position, and Side- Lying Position for Kidney Surgery laparotomy Kidney surgery Copyright © 2022 Wolters Kluwer · All Rights Reserved Protecting the Patient from Injury Patient identification Monitoring, modifying physical environment Correct informed consent Safety measures (grounding of Verification of records equipment, restraints, of health history, exam not leaving a sedated patient) Results of diagnostic tests Verification, accessibility of blood Allergies (include latex allergy) Copyright © 2022 Wolters Kluwer · All Rights Reserved  Question #3 Through which route are inhaled general anesthetics primarily eliminated? A. Kidneys B. Liver C. Lungs D. Skin Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #3 C. Lungs Rationale: Gas anesthetic agents are given by inhalation. When inhaled, the anesthetic agents enter the blood through the pulmonary capillaries and act on cerebral centers to produce loss of consciousness and sensation. When anesthetic administration is discontinued, the vapor or gas is eliminated through the lungs. Copyright © 2022 Wolters Kluwer · All Rights Reserved  Chapter 16 Postoperative Nursing Management Postanesthesia Care Postanesthesia Care Unit (PACU) Manage Phase I Respiratory, Pain o Immediate recovery , consciousness o Intensive nursing care o Patient transitions to an inpatient nursing unit or phase II PACU Phase II - more inpatient unit * o Prepared for transfer to an inpatient nursing unit, an extended care setting, or discharge Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Management in the Postanesthesia Care Unit (PACU) Provide care for patient until patient has recovered from effects of anesthesia Pre-Op Assessment * o Return to cognitive baseline Top Priority o Clear airway may need to suction Loading… o Controlled nausea and vomiting o Stable vital signs - monitoring continuous Vital to perform frequent skilled assessment of patient complications respiratory distress : Hemarrhage Copyright © 2022 Wolters Kluwer · All Rights Reserved Responsibilities of the PACU Nurse Review pertinent information, baseline assessment upon admission to unit Assess airway, level of consciousness, cardiac, respiratory, wound, and pain coughing deep , breath- Check drainage tubes, monitoring lines, IV fluids, ing , and medications Splinting Assess vital signs at the time of arrival to PACU and repeated per institution protocol Administration of postoperative analgesia Transfer report to another unit or discharge patient to home, continuing or transitional care, refer to Charts 16-1 and 16-3 Monitor Pain , Hypoxia bladder , distention everysmins for first hour ! Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #1 Is the following statement true or false? E The primary nursing goal in the immediate postoperative period is maintenance of pulmonary Loading… function and prevention of laryngospasm. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #1 False Rationale: The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of hypoxemia and hypercapnia. Copyright © 2022 Wolters Kluwer · All Rights Reserved Outpatient Surgery/Direct Discharge Discharge planning, discharge assessment Provide written, verbal instructions regarding follow-up care, complications, wound care, activity, medications, diet Give prescriptions, contact information o Discuss actions to take if complications occur Give instructions to patient, responsible adult who will accompany patient Patients are not to drive home or be discharged to home alone o Sedation, anesthesia may cloud memory, judgment, affect decision-making ability Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Management of the Hospitalized Postoperative Patient Assessment o Respiratory ! - vital signs under control o Pain -keep pain - Assess surgical site-dressings o Mental status/LOC - urine output o General discomfort must ambulate ! Teaching - Copyright © 2022 Wolters Kluwer · All Rights Reserved Maintaining a Patent Airway Primary consideration: necessary to maintain ventilation, oxygenation low PulseOX Provide supplemental oxygen as indicated - - Short of breath Assess breathing by placing hand near face to feel movement of air Take non-rebreather to assess Keep head of bed elevated 15 to 30 degrees unless contraindicated May require suctioning If vomiting occurs, turn patient to side Chest Assessment Shallow/rapid-pain for = Bi-lat ! Copyright © 2022 Wolters Kluwer · All Rights Reserved Head and Jaw Positioning to Open Airway Copyright © 2022 Wolters Kluwer · All Rights Reserved Use of Oral Airway Note: Do Not Remove Oral Airway Until Evidence of Gag Reflex Returns Loading… Copyright © 2022 Wolters Kluwer · All Rights Reserved Maintaining Cardiovascular Stability Monitor all indicators of cardiovascular status Assess all IV lines Potential for hypotension, shock volume blood Potential for hemorrhage of ~ loss Circulations Potential for hypertension, arrhythmias Refer to Table 16-1 ventilation hypo BP when Pt is on Do not check their side Copyright © 2022 Wolters Kluwer · All Rights Reserved Indicators of Hypovolemic Shock/Hemorrhage Just blood loss ! - Pallor of Pallor early sign - - - Shock Cool, moist skin Rapid respirations tachypnea Cyanosis Rapid, weak, thread pulse Decreasing pulse pressure Low blood pressure - hypotension Concentrated urine Copyright © 2022 Wolters Kluwer · All Rights Reserved Relieving Pain and Anxiety Assess patient comfort Control of environment: quiet, low lights, noise level Administer analgesics as indicated; usually short- acting opioids IV Family visit, dealing with family anxiety Nonpharmacologic, emotional, and psychological support Copyright © 2022 Wolters Kluwer · All Rights Reserved Controlling Nausea and Vomiting Intervene at first indication of nausea - alcohol swabs Medications Assessment of postoperative nausea, vomiting risk, prophylactic treatment Refer to Table 16-2 PRN for nausea - you must stay on it and treat continuously Lack of vomiting , not lack of nausea Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #2 O Is the following statement true or false? The nurse should intervene at the patient’s first report of nausea to control the problem rather than wait for it to progress to vomiting. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #2 True Rationale: The nurse should intervene at the patient’s first report of nausea to control the problem rather than wait for it to progress to vomiting. At the slightest indication of nausea, the patient is turned completely to one side to promote mouth drainage and prevent aspiration of vomitus, which can cause pneumonia, asphyxiation, and death. Copyright © 2022 Wolters Kluwer · All Rights Reserved Gerontologic Considerations Decreased physiologic Increased likelihood of reserve postoperative confusion, delirium 12 of all post- Monitor carefully, surgical older adults frequently Hypoxia, hypotension, hypoglycemia Increased confusion Reorient as needed when mutipe Dosage given meds Pain. Hydration POCD Post Cognitive Operative disorder Thermoregulation - at risk for hypothermia Refer to Chart 16-7 thermic response to hypoinfections Copyright © 2022 Wolters Kluwer · All Rights Reserved Wound Healing First-intention wound healing - suture , surgical inc. Second-intention wound healing - burn can't be Factors that affect wound healing sutured preopopes Age , bathing , - Refer to Chart 16-5 and Table 16-3 hemorrhage , blood poolinghypovolemia , Varo constriction open Don't Ice wound actively healing Hypothermia Copyright © 2022 Wolters Kluwer · All Rights Reserved  Question #3 Which of the following occurs during the inflammatory stage of wound healing? O A. Blood clot forms B. Granulation tissue forms C. Fibroblasts leave wound D. Tensile strength increases Copyright © 2022 Wolters Kluwer · All Rights Reserved  Answer to Question #3 A. Blood clot forms Rationale: The blood clot forms during the inflammatory phase of wound healing. Granulation tissue forms during the proliferative phase. Fibroblasts leave the wound and tensile strength increases during the maturation phase of wound healing, refer to Table 16-5 Copyright © 2022 Wolters Kluwer · All Rights Reserved Types of Surgical Drains - JP hemovac Copyright © 2022 Wolters Kluwer · All Rights Reserved Purpose of Postoperative Dressings Provide healing environment Absorb drainage Splint or immobilize Protect Promote homeostasis Promote patient’s physical and mental comfort Copyright © 2022 Wolters Kluwer · All Rights Reserved Change the Postoperative Dressing. 990 0 Sodium Chloride-Bacteria can't live in First dressing change can be done by nurse Sodium - order for what to use ! Types of dressing materials & much as possible privacy as towels Sterile technique - use blankets , Assess wound Applying dressing, taping methods Patient response Patient teaching Documentation Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Care of the Hospitalized Patient Recovering from Surgery Assess physiologic status Monitor for complications Manage pain Implement measures to achieve long-term goals Prosthetics are costly and insurance not like to pay always does. Copyright © 2022 Wolters Kluwer · All Rights Reserved Collaborative Problems 02 and send -Put on Pulmonary infection/hypoxia for Prevent X-rays Deep vein thrombosis/PE heparin after On surgery - Hematoma/hemorrhage Infection Wound dehiscence or evisceration until - soaked gauze Seen by surgeon to Sodium chloride keep from sticking. soaked Just lay on top ! gauze Immediate * Copyright © 2022 Wolters Kluwer · All Rights Reserved t antibiotics Managing Potential Complications VTE/PE Prevent immediate after - Blood thinners prevent and treat. surgery Hematoma - Bruising under skin-damage at site Infection of incision Wound dehiscence and evisceration I eternal contents incision out pushing separating internal flesh intact Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Process Assessment Diagnoses Planning and Goals Nursing Interventions Copyright © 2022 Wolters Kluwer · All Rights Reserved  Chapter 17 Assessment of Respiratory Function Overview of the Respiratory System Two tracts: nose , mouth , o Upper respiratory tract warms and filters air o Lower respiratory tract (the lungs) accomplishes gas exchange Together they deliver oxygen to and expel carbon dioxide from the body Works in conjunction with the circulatory system Copyright © 2022 Wolters Kluwer · All Rights Reserved The Respiratory System Loading… Copyright © 2022 Wolters Kluwer · All Rights Reserved Structures of the Upper Respiratory Tract #1 Nose: passageway for air to pass to and from the lungs (Figure 17-1) Paranasal Sinuses (Figure 17-2) o Frontal o Ethmoid o Sphenoid o Maxillary Pharynx, Tonsils, Adenoids nose o Nasal posterior to tonsils - o Oral alatine - facial P o Laryngeal to epiglotis flap opening Copyright © 2022 Wolters Kluwer · All Rights Reserved Structures of the Upper Respiratory Tract #2 ! The only quit always on usually wrong or connects to trachea Larynx - pharynx o Epiglottis -keep from aspirating o Glottis o Thyroid cartilage Loading… cartilage as o Cricoid cartilage onlysolid - a o Arytenoid cartilages lumen - o Vocal cords Trachea Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #1 Is the following statement true or false? The only function of the larynx is vocalization. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #1 False Rationale: Another name for the larynx is the voice box, and a primary function is to create vocal sounds. The larynx also serves as a barrier to foreign substances entering the lower respiratory tract and facilitates coughing. Copyright © 2022 Wolters Kluwer · All Rights Reserved Structures of the Lower Respiratory Tract #1 Two lungs, five lobes for heart o Left: upper and lower - space o Right: upper, middle, and lower Pleura - serus membrane Mediastinum - middle of thorax all thoracic tissue , outside of lungs Bronchi and bronchioles submucosal glands - lined w/ cilia-away Alveoli from extreme over production 300 , 000 , 000 -macrophages lungs - of sputum barrier Type I cells type a cells - surfactant production Copyright © 2022 Wolters Kluwer · All Rights Reserved Structures of the Lower Respiratory Tract #2 Copyright © 2022 Wolters Kluwer · All Rights Reserved  No Ventilation no Gas Exchange Ventilation is not toGas do exchange Functions of the Respiratory System #1 Oxygen transport - supplied co2 removed Respiration - whole gas exchange in body Ventilation inspiration/expiration process - o Air pressure variances of - Air flows from regionlower to region of higher pressure o Airway resistance Resistance is determined - by pressure radius size of airway through which air is flown Asthma or o Compliance one o Lung volumes and capacities (Table 17-1) Pulmonary diffusion and perfusion Ventilation and perfusion balance and imbalance (Chart 17-2) Copyright © 2022 Wolters Kluwer · All Rights Reserved Functions of the Respiratory System #2 Loading… where gas exchange happens Copyright © 2022 Wolters Kluwer · All Rights Reserved  Functions of the Respiratory System #3 Good Cardiac output Gas Exchanges "oxygen Bad Cardiac output o Partial pressure of gases build up of Carbon Dioxide o Oxyhemoglobin dissociation curve o Carbon dioxide transport o Neurologic control of ventilation respiratory center in the brainmedulla abegota and bons Copyright © 2022 Wolters Kluwer · All Rights Reserved Gas Exchange and Respiratory Function Copyright © 2022 Wolters Kluwer · All Rights Reserved  Question #2 Which groups of receptors assist in the brain’s control of the respiratory system? A. Chemoreceptors B. Mechanoreceptors C. Proprioceptors D. All of the above Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #2 D. All of the above Rationale: Chemoreceptors located in the medulla respond to chemical changes in the cerebrospinal fluid and work to maintain balance through increased or decreased respiratory rate. Mechanoreceptors are located in the lungs and respond to changes in resistance by altering inflation of the lungs. Proprioceptors are in the muscles and chest wall and respond to body movements to stimulate breathing. Copyright © 2022 Wolters Kluwer · All Rights Reserved Comprehensive Respiratory Assessment #1 Health history Presenting problems and associated symptoms o Onset o Location o Duration o Aggravating factors o Associated signs/symptoms o Impact on activities of daily living Copyright © 2022 Wolters Kluwer · All Rights Reserved Comprehensive Respiratory Assessment #2 Past health, social and family history o Childhood illnesses o Immunizations o Diet and exercise o Risk factors/genetics o Charts 17-6 and 17-7 Copyright © 2022 Wolters Kluwer · All Rights Reserved Physical Assessment #1 General appearance may give clues to respiratory status o Clubbing of the fingers takes a long time to develop o Skin color (cyanosis) - late indicator * Routine examination of the upper airway structures o Penlight Assessment of the lower respiratory structures o Inspection, palpation, percussion, auscultation o Chart 17-10 o Table 17-3 Copyright © 2022 Wolters Kluwer · All Rights Reserved Physical Assessment #2 Copyright © 2022 Wolters Kluwer · All Rights Reserved Physical Assessment #3 Copyright © 2022 Wolters Kluwer · All Rights Reserved Physical Assessment #4 Auscultation o Anterior, posterior, and lateral thorax o Normal, adventitious, and voice sounds Tables 17-5 and 17-6 o Sequence Similar to percussion Apices to bases to midaxillary lines Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment Findings Percussion note (resonant, hyperresonant, dull/flat) Tracheal position (midline vs. shifted) Breath sounds (vesicular, bronchial, decreased to absent) Adventitious sounds (crackles, wheezes, rhonchi, pleural rub) Tactile fremitus and transmitted voice sounds Table 17-7 Copyright © 2022 Wolters Kluwer · All Rights Reserved Diagnostic Evaluation #1 Pulmonary function tests (Table 17-8) Arterial blood gases Venous blood gas studies Pulse oximetry End-tidal carbon dioxide - measures output ! 21 + 02 * better indicator Cultures of respiratory condition Sputum studies than pulse of Imaging studies Copyright © 2022 Wolters Kluwer · All Rights Reserved Diagnostic Evaluation #2 Fluoroscopic studies Radioisotope procedures (lung scans) Endoscopic procedures Thoracentesis - Thor Biopsies Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #3 Is the following statement true or false? Sputum samples are best collected immediately before bed. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #3 C False Rationale: Sputum samples are used to diagnose infectious processes and evidence of malignant cells. The ideal time to obtain a sputum specimen is early in the morning before the patient has had anything to eat or drink. The patient should clear the nose and throat, then rinse the mouth to avoid contamination of the sample. The patient should be instructed to take a few deep breaths, cough, and expectorate sputum into a sterile container. Copyright © 2022 Wolters Kluwer · All Rights Reserved  Chapter 18 Management of Patients with Upper Respiratory Tract Disorders Management of Patients With Upper Respiratory Infections (URIs) Fperyearult Most common cause for illness, reason for seeking health care and absences from school and work except nursing school ! May be minor, acute, chronic, severe, or life threatening treatment only seen in Treated in community settings: doctor offices, urgent care clinics, long-term care facilities, or self-care at home Early detection of signs and symptoms and appropriate interventions can avoid unnecessary complications Patient teaching focus on prevention and health promotion Special considerations for older adults: Refer to Chart 18-1 Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #1 Is the following statement true orE false? The term “common cold” refers to an infectious, chronic inflammation of the mucous membranes of the Loading… nasal cavity requiring hospitalization and treatment with IV antibiotics. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #1 False Rationale: The “common cold” is acute inflammation of the nasal cavity that is typically self-limiting with nasal congestion, rhinorrhea, sneezing, sore throat, and general malaise. The term is used with acute URIs such as rhinitis, pharyngitis, and laryngitis and often when the causative agent is the influenza virus. Copyright © 2022 Wolters Kluwer · All Rights Reserved Bacterial if purulent Antihistaminsstate virus shed lasts 2 days , asymptomatic for 2 days pg 496 Epistaxis - Emergent sometimes with airway compromise Hemorrhage from the nose Anterior septum, most common site Serious problem, may result in airway compromise or significant blood loss Loading… Risk factors, refer to Chart 18-5 Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical Management of Epistaxis Identify cause and location Pinch soft portion of nose for 5 to 10 minutes, patient sits upright Phenylephrine spray, vasoconstriction slowing bleeding Cauterize with silver nitrate or electrocautery Gauze packing or balloon-inflated catheter inserted into nasal cavity for 3 to 4 days posterior bleed - Antibiotic therapy Copyright © 2022 Wolters Kluwer · All Rights Reserved Control of Epistaxis—Packing of Nasal Cavity or Balloon Catheter Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Management of Epistaxis Airway, breathing, circulation Vital signs, possible cardiac monitoring and pulse oximetry Reduce anxiety Patient teaching: o Avoid nasal trauma, nose picking, forceful blowing, spicy foods, tobacco, exercise o Adequate humidification to prevent dryness o Pinch nose to stop bleeding; if bleeding does not stop in 15 minutes, seek medical attention Copyright © 2022 Wolters Kluwer · All Rights Reserved URIs Rhinitis and rhinosinusitis: acute, chronic, bacterial, viral (Charts 18-2 and 18-3) Pharyngitis: acute, chronic Tonsillitis, adenoiditis Peritonsillar abscess Laryngitis Copyright © 2022 Wolters Kluwer · All Rights Reserved Rhinitis and Rhinosinusitis Copyright © 2022 Wolters Kluwer · All Rights Reserved Pharyngitis Loading… Reprinted with permission from the Wellcome Trust, National Medical Slide Bank, London, UK. Copyright © 2022 Wolters Kluwer · All Rights Reserved  - droplet/unclean hands Bacterial swab Streb  /fatigue bacterial Do not typically haverough Potential Complications and Collaborative Problems with URIs prolonged Airway obstruction Medicamentosa - Use of medications Hemorrhage Acute otitis media Sepsis Trismus - inability to open mouth "Lock jaw" Meningitis or brain Dysphagia - I abscess Stiff neck sign Aphonia lose of voice Nuchal rigidity Cellulitis - inflammation Copyright © 2022 Wolters Kluwer · All Rights Reserved  Question #2 What should the nurse recommend a patient with pharyngitis avoid? A. ENDS use B. Exposure to extreme heat C. Secondhand smoke O D. A and C Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #2 D. A and C Rationale: Patients diagnosed with chronic pharyngitis should avoid alcohol, tobacco, secondhand smoke, ENDS use, exposure to cold and environment and occupational pollutants. The patient can wear a disposable face mask to filter out small particles such as dust and mold. This patient should also stay hydrated with oral fluids and use lozenges or gargle with warm saline solution to relieve throat discomfort. Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment of the Patient with URI Health history Signs and symptoms: headache, cough, hoarseness, fever, stuffiness, generalized discomfort, and fatigue Allergies Inspection of nose, neck, throat, and palpation of lymph nodes Copyright © 2022 Wolters Kluwer · All Rights Reserved Planning and Goals for the Patient with URI Early detection is key ! Comorbidities need treatment Airway management, reduce risk of aspiration Pain management Effective communication strategy Normal hydration Patient teaching: prevention of URI, and absence of complications Copyright © 2022 Wolters Kluwer · All Rights Reserved  - will have to drain absess - wide Nursing Interventions for the Patient with URI Elevate head Gargles for sore throat Salt : water Ice collar to reduce Use alternative inflammation and communication bleeding Encourage liquids and Hot packs to reduce use of room vaporizers congestion or steam inhalation to keep secretions loose Analgesics for pain and moist for easier Topical anesthetics expectoration Monitor for severe Rest complications Copyright © 2022 Wolters Kluwer · All Rights Reserved Evaluation of the Patient with URI Maintenance of patent airway Expresses relief of pain Able to communicate needs Evidence of positive hydration Free of signs and symptoms Absence of complications Copyright © 2022 Wolters Kluwer · All Rights Reserved Patient Education for URI Prevention of upper airway infections Emphasize frequent hand washing When to contact health care provider Need to complete antibiotic treatment regimen Annual influenza vaccine for those at risk Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment of the Patient Undergoing Laryngectomy Health history Physical, psychosocial, and spiritual assessment Nutrition, BMI, albumin, glucose, electrolytes Literacy, hearing, and vision; may impact communication after surgery * key' * Coping skills and available support systems for patient and family after surgery Copyright © 2022 Wolters Kluwer · All Rights Reserved Collaborative Problems and Potential Complications for the Patient Undergoing Laryngectomy Respiratory distress hypoxia , airway obstruction tracheal edemia Hemorrhage Infection Wound breakdown Aspiration Tracheostomal stenosis Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient Undergoing Laryngectomy Preoperative teaching Reduce anxiety Maintain patent airway, control secretions Support alternative communication#call bell writing board * Promote adequate nutrition and hydration Promote positive body image, self-esteem Monitor for potential complications Self-care management; homecare (Chart 18-7) Copyright © 2022 Wolters Kluwer · All Rights Reserved  Question #3 What is a priority education component for a patient scheduled for a total laryngectomy? A. Clarify misconceptions after the patient speaks with the provider B. Discuss the effect of surgery on speech postoperatively C. Explain methods for communication postoperatively O D. All of the above Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #3 D. All of the above Rationale: Patients may experience severe anxiety at the thought of waking up from surgery and not being able to speak. Preoperatively, the nurse must clarify any misconceptions regarding the procedure and outcomes, discuss alternative strategies for communication after surgery, and reinforcement of teaching with patient and family that the patient’s natural voice will be lost. Copyright © 2022 Wolters Kluwer · All Rights Reserved  Chapter 19 Management of Patients with Chest and Lower Respiratory Tract Disorders Atelectasis Closure or collapse of alveoli Acute or chronic Most common is acute atelectasis, which occurs in the postoperative setting gradual-(stealthily narmful) Symptoms: insidious, increasing dyspnea, cough, and sputum production Res 105 or more 20-20 - Acute: tachycardia, tachypnea, pleural pain, and central cyanosis if large areas of the lung are affected Chronic: similar to acute, pulmonary infection may be present Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment and Diagnosis for Atelectasis Characterized by increased work of breathing and hypoxemia Decreased breath sounds and crackles over the affected area Loading… Chest x-ray may suggest a diagnosis of atelectasis before clinical symptoms appear Pulse oximetry (SpO2) may demonstrate a low saturation of hemoglobin with oxygen (less than 90%) Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for Atelectasis Prevention o Frequent turning o Early mobilization o Strategies to expand lungs and manage secretions o Incentive spirometer lots of teaching o Voluntary deep breathing o Secretion management increase o Pressurized metered-dose inhaler to effectiveness of bronchiodialators Copyright © 2022 Wolters Kluwer · All Rights Reserved Management of Atelectasis Improve ventilation and remove secretions First-line measures: o Frequent turning, early ambulation, lung volume expansion maneuvers and coughing 15 Loading… Multidisciplinary: ICOUGH (see Chart 19-3) continuous Pressure PEEP, CPAB, bronchoscopy Airway breathing setting onvents CPT Chest Physical Therapy Endotracheal intubation and mechanical ventilation Thoracentesis to relieve compression Copyright © 2022 Wolters Kluwer · All Rights Reserved Acute Tracheobronchitis Antibiotic treatment Inflammation of the mucous membranes of the trachea usually after a viral infection Pathophysiology o Mucopurulent sputum - must have a sputum Sample per book Clinical manifestations - o Initially dry cough with mucoid sputum o As progresses, dyspnea, stridor, wheezes, purulent sputum Copyright © 2022 Wolters Kluwer · All Rights Reserved Management of Acute Tracheobronchitis Medical management Antihistamines will out more o Antibiotics dry o Analgesics o Increased fluid intake o Cool vapor therapy or steam inhalations o Suctioning side usually on the dryer Nursing Management I o Bronchial hygiene cough effectively o Rest Don't just lay and let fluids build up o Complete full course of medications Copyright © 2022 Wolters Kluwer · All Rights Reserved Pneumonia functional tissue of - the lungs Inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, fungi, and viruses Classification o Community-acquired (CAP) o Health care–associated (HCAP) o Hospital-acquired (HAP) o Ventilator-associated (VAP) o Refer to Chart 19-4 Copyright © 2022 Wolters Kluwer · All Rights Reserved Types of Pneumonia #1 Community-acquired o Community setting or within first 48 hours post hospitalization o Rate of infection increases with age - Less than Go o S. Pneumoniae is the most common cause among adults o Viral origin in infants and children - watch it ! Health care–associated o Often caused by multidrug-resistant organisms o Early diagnosis and treatment are critical Copyright © 2022 Wolters Kluwer · All Rights Reserved Types of Pneumonia #2 Hospital-acquired o Develops 48 hours or more after hospitalization o Subtype of health care–associated pneumonia o Potential for infection from many sources o High mortality rate o Colonization by multiple organisms due to overuse of antimicrobial agents o Sepsis esentation Pleural effusion, high fever, and tachycardia o Common with debilitated, dehydrated patients with minimal sputum production Copyright © 2022 Wolters Kluwer · All Rights Reserved  plan ahead for Types of Pneumonia #3 extubation Ventilator-associated o Received mechanical ventilation for at least 48 hours o Prevention is key But Prophalaxis topiority o VAP bundles (Chart 19-6) oral care Loading… Pneumonia in the immunocompromised host ! o Common agents include pneumocystis, fungi, and tuberculosis o Receiving immunosuppressive agents, history of immunosuppressive condition o Subtle onset with progressive dyspnea, fever, and nonproductive cough Immuno suppress have subtle symptoms more. Copyright © 2022 Wolters Kluwer · All Rights Reserved Pneumonia Risk Factors Refer to Table 19-2 Occurs in patients with certain underlying disorders and diseases o Heart failure, diabetes, alcoholism, COPD, and AIDS o Influenza Cystic fibrosis secretions - thick sticky Copyright © 2022 Wolters Kluwer · All Rights Reserved Clinical Manifestations of Pneumonia Varies depending on type, causal organism, and presence of underlying disease Bacterial Pneumonia Streptococcal: Sudden onset of chills, fever, pleuritic - chest pain, tachypnea, and respiratory distress Viral, mycoplasma, or Legionella: relative bradycardia fever with notever /No associated tachycardia - Other: Respiratory tract infection, headache, low- grade fever, pleuritic pain, myalgia, rash, and pharyngitis -vibrating of chest Orthopnea, crackles, increased tactile fremitus, purulent sputum Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment and Diagnosis of Pneumonia History Physical exam Chest x-ray test for Blood culture to type for antibacterial proper Sputum examination Bronchoscopy may be used for acute severe infection Copyright © 2022 Wolters Kluwer · All Rights Reserved Pneumonia Prevention Pneumococcal vaccination o Reduces the incidence of pneumonia, hospitalizations for cardiac conditions, and deaths in the older adult population o Two types of pneumococcal vaccine o Recommended for all adults 65 years of age or older and 19 years or older with conditions that weaken the immune system Other preventive measures, see Table 19-2 Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical Management of Pneumonia Administration of the appropriate antibiotic as determined by the results of a culture and sensitivity Supportive treatment includes fluids, oxygen for hypoxia, antipyretics, antitussives, decongestants, and antihistamines Antibiotics not indicated for viral infections but are used for secondary bacterial infection Refer to Table 19-3 used for prevention of Gerontologic considerations secondary infetions Copyright © 2022 Wolters Kluwer · All Rights Reserved COVID-19 Considerations SARS-CoV-2 Asymptomatic to severe viral pneumonia Fatigue, myalgia, congestion, sore throat, diarrhea, anosmia, and ageusia Mostly conservative outpatient management (rest, hydrate, antipyretic agents) Hospitalization for severe illness with pneumonia, increased risk of venous thromboembolism Can lead to shock and respiratory failure Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment of the Patient with Bacterial Pneumonia Vital signs Secretions: amount, odor, color Cough: frequency and severity Tachypnea, shortness of breath Inspect and auscultate chest Changes in mental status, fatigue, edema, dehydration, concomitant heart failure, especially in older adult patients Copyright © 2022 Wolters Kluwer · All Rights Reserved Problems/Complications of the Patient with Bacterial Pneumonia Continuing symptoms after initiation of therapy Sepsis and septic shock Respiratory failure Atelectasis Pleural effusion Delirium Copyright © 2022 Wolters Kluwer · All Rights Reserved Planning and Goals for the Patient with Bacterial Pneumonia Improved airway patency Increased activity Maintenance of proper fluid volume Maintenance of adequate nutrition Understanding of the treatment protocol and preventive measures Absence of complications Based on patient outcomes plan for home, community, and transitional care Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient with Bacterial Pneumonia Oxygen with Incentive spirometry humidification to loosen secretions Nutrition o Face mask or nasal Hydration cannula Rest Coughing techniques Activity as tolerated Chest physiotherapy Patient education Position changes Self-care Copyright © 2022 Wolters Kluwer · All Rights Reserved Expected Outcomes for the Patient with Bacterial Pneumonia Demonstrates improved airway patency Rests and conserves energy and then slowly increasing activities Maintains adequate hydration; adequate dietary intake Verbalizes increased knowledge about management strategies Complies with management strategies Exhibits no complications Copyright © 2022 Wolters Kluwer · All Rights Reserved Aspiration Inhalation of foreign material into the lungs leads to inflammatory reaction, hypoventilation, and ventilation–perfusion mismatch Serious complication is broncho or lobar pneumonia Risk factor is LOC; refer to Chart 19-8 Key pathophysiology is the volume and character of aspirated contents (most often GI contents) Copyright © 2022 Wolters Kluwer · All Rights Reserved Aspiration Prevention Swallowing screening Nursing interventions o Keep HOB elevated and endotracheal cuff elevated (if intubated) o Avoid stimulation of gag reflex with suctioning or other procedures o Check for placement before tube feedings o Soft diet, small bites, no straws Refer to Chart 19-9 Copyright © 2022 Wolters Kluwer · All Rights Reserved Pulmonary Tuberculosis Mycobacterium tuberculosis bacillus (TB) 10 million people with TB worldwide and 9,105 cases in the United States (2017) Spreads by airborne transmission through droplets then moves to other parts of the body such as the kidneys, bones, and cerebral cortex. Granulomas and Ghon tubercule Risk factors for TB, refer to Chart 19-10 Low-grade fever Cough; nonproductive or mucopurulent; hemoptysis Night sweats, fatigue, weight loss Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment and Diagnostic Findings for TB History and physical TB skin test; Mantoux method: See Figure 19-3 o Significant versus nonsignificant reactions TB blood tests Sputum culture Sputum testing Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical Management of TB Treated for 6 to 12 months Drug resistance is primary concern Initiate treatment with four or more medications Complete all therapy o Initial treatment phase (8 weeks) o Continuation phase (4 to 7 months) Table 19-4 Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Management of TB Promoting airway clearance Advocating adherence to the treatment regimen Promoting activity and nutrition Preventing transmission Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #1 Is the following statement true or false? Once a patient recovers from tuberculosis they cannot develop an active case in the future. Loading… Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #1 False Rationale: When a patient recovers from TB, the bacteria and macrophages become necrotic and form a calcified fibrous masse, a Ghon tubercle. At this point, the bacteria become dormant. However, future reinfection and activation of the dormant bacteria are possible with bacteria becoming airborne and further spreading the disease. Copyright © 2022 Wolters Kluwer · All Rights Reserved Lung Abscess Most are a complication of bacterial pneumonia Symptoms vary from a mild productive cough to acute illness; plueral friction rub Site of lung abscess related to gravity and determined by position Can lead to empyema, bronchopleural fistula Symptoms vary from a mild productive cough to acute illness, productive cough with foul sputum, leukocytosis, pleurisy, dyspnea, weakness, anorexia, and weight loss Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment and Diagnostic Findings for Lung Abscess Pleural friction rub Crackles Chest x-ray Sputum culture Bronchoscopy CT of the chest Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical Management of Lung Abscess Prevention Adequate drainage of the lung Chest physiotherapy Diet high in protein and calories Antimicrobial therapy Pulmonary resection (rare) Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Management of Lung Abscess Administer IV antibiotics CPT Educate patient to perform deep breathing and coughing exercises Encourage diet high in protein and calories Emotional support Promote home, community-based, and transitional care Copyright © 2022 Wolters Kluwer · All Rights Reserved Sarcoidosis Occurs between 20 and 40 years of age More common in African American women Interstitial lung disease that is inflammatory, multisystem, granulomatous with unknown