Med Surg Mod 8 Ch 9,12 PDF

CHAPTER 9 Shock:. Circulatory collapse resulting in organ damage and death without immediate treatment. Pathology of Shock: (Inadequate Tissue Perfusion) - Tissue perfusion and B / P are maintained by:. Adequate blood volume. Effective cardiac pump. Effective blood vessels - Compensation...

CHAPTER 9 Shock:. Circulatory collapse resulting in organ damage and death without immediate treatment. Pathology of Shock: (Inadequate Tissue Perfusion) - Tissue perfusion and B / P are maintained by:. Adequate blood volume. Effective cardiac pump. Effective blood vessels - Compensation (Compensatory Mechanism). Once system fails and changes are made in one or both of non-failing systems. Shock occurs when compensatory mechanism fails. Metabolic &Hemodynamic changes in shock: - Sympathetic Nervous System:. Tachycardia. Tachypnea. Oliguria. Cool, clammy skin with pallor. Decreased Blood Pressure Effect on Organs & Organs systems:. Tissue Ischemia & Organ injury. Brain death if anoxic over 4 minutes Complications from Shock:. Acute Respiratory Distress Syndrome (ARDS). Disseminated intravascular coagulation (DIC). Multiple organ dysfunction syndrome (MODS) Classification of Shock: - Hypovolemic shock= Decreased circulating blood volume - Cardiogenic shock= Cardiac failure - Obstructive shock= Blockage of blood flow outside heart - Distributive shock= Excessive dilation of venules/arterioles Characteristics of all shock is decreased blood pressure below level to maintain adequate blood flow to tissues. Hypovolemic Shock:. Decreased circulating volume.. Any severe loss of body fluid including dehydration. - Causes:. Dehydration, hemorrhage. Loss of fluid from burns, vomiting, diarrhea, or intravascular into interstitial space - Signs and Symptoms:. Restlessness altered mental status.. Pale, cool, clammy skin. Tachycardia, tachypnea. Non-distended peripheral veins decrease jugular vein circumference.. Decrease urine output. Cardiogenic Shock:. Cardiac failure, heart fails to adequately pump blood to the body. - Causes:. Acute Myocardial Infarction. Rupture of heart valve. Acute Myocarditis/Cardiomyopathy. End stage heart disease. Severe Dysthymias (A-FIB). Traumatic injury to the heart - Signs & Symptoms:. Similar to Hypovolemic. Distended jugular & peripheral vein.. Pulmonary edema. Extreme SOB. Wheezing & Gasping for a breath. Coughing White frosty sputum Obstructive Shock:‼️KNOW THIS‼️‼️. Blocked blood flow outside the heart. - Cause:. Pericardial Tamponade= Pericardial sac fills with blood. Tension Pneumothorax= Compression of heart with air in pleural spaces. Acute pulmonary hypertension= Increase pressure in pulmonary artery - Signs & Symptoms:. Similar to Hypovolemic. Distended Jugular Distributive Shock:. Peripheral vascular is lost due to excessive dilation of venules/arterioles - 3 Types:. Anaphylactic Shock. Septic Shock. Neurogenic Shock  Anaphylactic Shock:. Extreme Hypersensitivity reaction to antigen, death in minutes. - Causes:. Insect stings, antibiotics, peanuts, anesthetics, dye, blood. - Signs & Symptoms:. Similar to hypovolemic shock. Allergic reactions, rash, urticaria, laryngeal edema, severe bronchospasm.. Conscious: SOB, metallic taste.. Administer Epinephrine (Adrenaline) Remember First action as a Nurse is to MAINTAIN PATIENTS' AIRWAY!!!!! This is your highest priority. Septic Shock:. Systemic Infection and inflammation - Causes:. Gram Negative Bacteria. Multi-drug Resistant - Predisposing Conditions: ‼️‼️ know these!!. Trauma. Diabetes. Corticosteroids therapy. HIV. Chemotherapy. Burns. Malnutrition. Invasive catheters - Septic shock can occur from infection - There is extreme Hypoperfusion Signs & Symptoms: - Early Phase:. Warm/flushed skin. Fever, elevated WBCs. Decreased BP, tachycardia. Tachypnea - Second Phase:. Decreased B/P. Non-Distended Jugular & Peripheral Veins. Cold clammy skin. Tachypnea. Oliguria. Temperature decreases to normal or subnormal. AMS (altered mental status) *Leading cause of death in critically ill patients Neurogenic Shock:. Dysfunction or injury of the nervous system, dilation of peripheral blood vessels. -Causes:. General anesthesia. Fever. Metabolic disturbances. Brain contusions/concussions - Signs and Symptoms:. Decreased B / P altered mental Status.. Early s/s: Bradycardia, warm dry skin.. Late s/S: Tachycardia, cool clammy skin. Classic Signs of Shock:. Tachycardia. Tachypnea. Oliguria. Pallor, cool and clammy skin Therapeutic Measures for Shock:. Maintain Airway/Respiratory support.. Provide Cardiovascular support.. Maintain Circulatory volume.. Control bleeding. Treat cause & identity source of infection. Nursing Care:. Maintain Airway (put pt. On oxygen). Monitor V/S. Monitor I’s & O’s. Provide warmth.. Relieve Pain. Monitor for pressure Injury (vasopressor use) CHAPTER 12 Care for surgical patients: - Suffixes:. Ectomy: Removal by cutting. Oscopy: Looking into. Ostomy: Formation of a permanent artificial opening. Otomy: Incision or cutting into. Plasty: Formation or repair Surgery Urgency Level:  Purpose of Surgery: Types of Surgery:. Open incision. Minimally invasive surgery - Examples:. Endoscopic (keyhole). Scope (Laparoscopic & Thoracoscopic). Robotic. Laser  - Outpatient:. Stand-Alone surgery center. Medical office. Hospital outpatient surgery department - Inpatient:. Hospital-Based surgery. Requires patient to be admitted onto a unit within the hospital. Typically requires more than 24hrs in the hospital overnight for observation of to continue more medical treatment. Perioperative Phases: - Pre-Operative:. Decision for surgery until transfer to surgery. - Intra-Operative:. Transfer to surgery to perianesthesia care (PACU) - Postoperative:. PACU through recovery Our Goal as nurses is to identify and implement actions that reduce surgical risk factors. Factors influencing Surgical outcomes:. Age- causes stress on the body and makes it difficult to compensate due to declining physiological reserve. When in pre-op pad bony prominences. Intra-op monitors for hypoxia (restlessness), hypothermia, hemorrhage, and Is&Os. Post-Op provides pain control and monitors respiratory function (deep breathing exercises) and encourage mobility. Monitor bowel function and urinary function as well as delirium.. Chronic Disease. Emotional response. Nutrition. Smoking & Alcohol & Drug abuse (if patient smokes tell them to avoid smoking 24hr before surgery, if the patient has a lung disorder tell them to quit smoking 3-4 weeks before surgery) Pre-Admission surgical patient assessment: - Non-emergent surgical patients have a preoperative assessment and an interview with an anesthesiologist or RN.. Obtain pts. Health history, medications (herbs and supplements as well). Physical assessment. Risk factors. Teaching-. Discharge planning. Referrals. Diagnostic testing/Labs (reviewed by anesthesiologist before surgery). Advance directives  - Preoperative Routines:. Date and time of surgery. Admission time (Arrive about 2hrs before surgery). Length of stay. Recovery after surgery. Family information. Discharge criteria (if patient is having an outpatient surgery the patient will need another adult to take them home) - Pre-operative Education:. Pre-Op procedures and special preps are explained.. Medication instructions as to what meds to take in the morning of surgery are explained (They can take with an ounce of water) NPO after midnight to prevent aspiration.. Instructions for postoperative care are given before surgery. This allows the patient to be alert for the teaching and have time for practice. - Post-Op Care:. Teach deep breathing exercises, coughing and use of an incentive spirometer. (Deep breathing exercises are repeated hourly while awake in sets of five, for 24-48hrs post- op). Pain management. PT/OT evaluation, exercises, and ambulation are taught. - Incentive Spirometry:. Sit Upright 45 Degrees. Take two normal breaths. Place the mouthpiece of spirometer in mouth.. Inhale until the target, designated by spirometer light or rising ball, is reached, and hold breath for 3 to 5 seconds.. Exhale completely.. Perform 10 sets of breaths as ordered.. Splint incision with pillow, ask patient to cough every 1-2hrs while awake. Coughing moves secretions to prevent pneumonia. Reinforce teaching on how to cough effectively if not contraindicated by the patient's condition. Give pain medication before asking the patient to cough. Reassure patient that coughing should not harm the incision. Splinting the incision with a pillow may be comforting. Several sets of coughing are performed every 1 to 2 hours while the patient is awake. THIS WILL PREVENT RESPIRATORY COMPLICATIONS!!!!! Pre-Op Nursing Diagnosis:. Anxiety. Fear. Deficient Knowledge Inform patients about procedures and surgical routines, which helps reduce anxiety. Allow patients to express their concerns to allow inaccurate information to be corrected.  If patients express extreme anxiety or fear, inform the surgeon because complications or even death could result. Provide the opportunity to listen to music or use guided imagery, which can help reduce patient's anxiety and fears. Pre-Op Consent: (Protects the patient). Written consent (Voluntary, no persuasion or threats can be used to obtain). Patients give legal permission for surgery.. No analgesics or sedation before signing consent.. Valid for 30 DAYS - Nurses role is to WITNESS the patient or authorized person signed the consent. Advocate patients understanding and questions are answered before signing. If patient is unable to read, read it to the patient Pre- Op check list:. ID band/Gown. VS. Remove make up, nail polish, wigs, and metal.. Remove dentures, contact lenses, prostheses, glasses, and hearing aids.. All orders, diagnostic test results, consents, and H&P are reviewed.. Valuables given to family and documented or locked up per institutional policy.. Anti-embolism devices. Void before sedating medications are given, unless urinary catheter is placed. Pre-Op Medications:  Transfer to Surgery:. Holding area. Verifications. Patient Data. Surgical site. Patient initials/Marks operative site. Time out (Always call for a timeout before procedure begins). IV insertion. IV antibiotic. Pre-Warming (To prevent from hypothermia) Intra-Operative Phase:. Explain to patient what to expect. Position. Safety. Tubes placed after anesthesia induction.. Skin prep (CHG). LVN role- Scrub nurse, sterile instrument field, assist surgeon. Intra-Op care:. Surgical team Scrub person Sets up surgical instruments and supplies Participates in sponge, needle, surgical blade, and instrument count Gowns and gloves operating team; hands instruments to operating team Maintains sterile technique at all times Circulating Nurse:. Is responsible for the safety of the patient. Supervises scrub person, observes for breaks in technique, participates in sponge/instrument counts. Provides additional instruments or supplies as needed. Gowns and gloves members of the operating team. Checks function of equipment used during surgery. Takes charge of tissue specimens. Provides blood and IV solutions as needed Anesthesia:. General anesthesia. Loss of sensation, consciousness, reflexes. IV or inhalation route. Endotracheal intubation. Complication: Malignant hyperthermia  Malignant Hyperthermia:. Rare hereditary muscle disease. Triggered by some general anesthesia agents/succinylcholine. Potentially fatal. Surgery stopped, anesthesia discontinued. 100% oxygen given. Cooled with ice, iced IV solutions. Dantrolene sodium, IV muscle relaxer given - Signs & Symptoms:. High Fever. Muscle rigidity. Tachycardia. Hypertension - Complications:. Leaking of cerebrospinal fluid. Hypotension. Severe headache. Worst Standing. Position patient flat. Force fluids IV conscious sedation:. Sedatives, hypnotics, and opioids. Selected procedures Endoscopy, dental, colonoscopy, cardiac cath. Very close monitoring. Emergency equipment available Post-Op phase:. Provides care to patients who have had general anesthesia or spinal anesthesia and/or who require constant observation after a surgical invasive procedure - Nursing Care:. Maintain patent airway. Position on side or head turned to side. VS every 5-15 minutes including O2 saturation. O2 administration/suction PRN 1&. Monitor tubes/drains/dressing. Pain control. Arouse patient (LOC) encourage deep breathing. Temperature control Respiratory Function: - Complications:. Hypoventilation. Increased secretions. Decreased swallowing/cough reflexes - Nursing Action:. Assess airway, respiration, lung sounds, and subjective signs; SOB , fatigue. Position on side. Suction PRN. O2 administration. Deep breathing and cough. Pain control. Maintain CPAP/BIPAP for sleep apnea.. Monitor respirations closely - Prevention:. Encourage coughing and deep-breathing and use of incentive spirometer. Cardiovascular/Circulatory Function: - Complications:. Hypotension/Hypertension. Dysrhythmias - Assessment:. HR, Blood Pressure, ECG, Skin temp, color, & moistness - Nursing Actions:. Check dressing & Incision for color and amount of drainage. IV fluids, strict Is&Os. Pain relief, monitor core body temp, warm patient, monitor vitals. Report S/S of Hypovolemic shock stat - Prevention:. Monitoring blood pressure and skin temperature encourage activity and leg exercises; anti-embolus stockings (TED) and SCD's help to promote circulation neuromuscular checks. Neurological Function:. Agitation. Amnesia Altered movements, sensation perceptions. - Assessment:. LOC, orientation. Pupil reaction. Motor and sensory function - Nursing Action:. Side rails up, restraints. Secure tubes, check dressings.. Provide re-orientation.. Assess for signs of pain. Discharging from PACU:. Stable vital signs. Oxygen saturation greater than 90 %. Awake, baseline level of consciousness. Respirations not depressed.. Bleeding controlled Initial Post-Op Assessment:. Respiratory status - airway respiration, lungs. Circulatory status- pulses, skin, temp. Neurological status - LOC, orient, gag. Incision/dressing location, drainage, tubes. Comfort- pain, N/, NG, bladder distended.. Post-op VSQ15 mins hr; Q 30 mins x 2 hr; hr x 4 hr. Tubes/drains. IV fluids. Safety protocol. Spinal anesthesia - safety issues, watch B/P closely, spinal HA Providing Comfort Post-Op Interventions: - Pain Control:. Opioid Analgesics (PO, SubQ, IM, IV, epidural, PCA); SE; Depress respiratory function, N/V. Non-narcotic analgesics (along with opioids). Giving pain meds on schedule for first 2 days. Post-Op increase compliance with activity, lung exercises.. Troubleshoot- dressing too tight, bladder distention, cold room, anxiety, N/ V Promoting Comfort Post-Op interventions:. Nausea/Vomiting - usually only 12-24 hrs postop; antiemetic; mouth care; NG.. Gas- antacids/anti- flatulents; no straw; walking, gentle massage. Thirst wet washcloth; ice chips. Constipation - fluid intake; fiber; stool softener. Promoting rest - grouping treatments /procedures; music/ distraction; include family in plan of care. Urinary Function Post-Op Interventions: - Urinary retention: (Most common problem after surgery). Clients need to void at least every 8 hours; more often for certain surgeries.. Urinary output should be at least 30mL per hour.. Non- invasive techniques to assist with voiding (run water, privacy, sit up). LAST resort: contact MD to insert a foley catheter, if needed GI Function Post-Op Interventions:. Being NPO and having bowel prep may occur Pre-Op. After abdominal surgery peristalsis, bowel sounds, and flatus usually stop (paralytic ileus). This may last for 24 to 72 hours.. Flatus, bowel movements, and an appetite signal the return of gastrointestinal (GI) function. - Interventions to shorten ileus time include the following:. Minimally invasive surgery. Alvimopan (Entereg ) 12 mg given (in a hospitalized setting only) 30 to 90 minutes before surgery and twice daily for up to 15 doses only in 7 days (risk of myocardial  infarction) this increases recovery of the functioning of the GI tract after partial small or large bowel resections.. Early ambulation as ordered Chewing gum Early feeding as ordered Avoidance of NG tubes, as complications and delayed feeding can occur. Mobility Post-Op Interventions: - Leg: Leg exercises every 2 hours while awake - Dangle: Note Dizziness - Ambulate: ambulate within 12hrs. Of Surgery progress as tolerated - Turn: If bedridden, turn Q2 hrs. PROM & AROM as tolerated Wound Healing: - First Intention:. Wound edges are closed and a scab forms. Most surgical wounds heal by first intention.. Minimal scarring - Second Intention:. Edges are far apart. Tissue loss/necrosis. Usually left open to heal by granulation tissue. EX: Pressure ulcer - Third Intention:. Infected wound left open until no sign of infection then surgically closed Interferences with wound healing:. Smoking. Corticosteroids. Wound infections. Suppressed immune systems (stress, emotional disturbances, meds). Vomiting, abdominal distention, deep cough - Sanguineous - Serosanguineous - Serous Post-Op Wound care: - Dressings:. Check when vitals are done for the first 24 hours. Reinforce as needed. Record amount and characteristics of drainage - Suture/ Staple: (Removing). Long incision, remove every other suture starting with second suture. Apply steri-strips Possible Complications: - Dehiscence:. Separation of some or all layers of the surgical wound.. Usually occurs on 5th to 12th post-op day -Evisceration:. Content of abdominal cavity protrude through incision. Position the client in low Fowler's position with knees flexed. Cover wound with sterile dressings or clean towels moistened with warm sterile normal saline.. Notify surgeon immediately. Monitor vital signs for evidence of shock. Infuse IV fluids as ordered.. Prepare for immediate surgery *Highest risk pts: obese, malnourished, dehydrated, multiple traumas to abdomen, infected wound Ambulatory Surgery: - Monitoring patient in PACU:. Airway, vitals, neuro status, I’s and O's, wound pain. When gag reflex returns give PO liquids. usual stay is one to three hours. Ambulate ASAP - Before going home:. Ambulate. Empty bladder. Gag reflex. Tolerating liquids