Med Surg Quiz 1 PDF

Med Surg Quiz 1 Chapter 6: Nursing Care of Patients with Fluid, Electrolyte, and Acid-Base Imbalances Fluid Balance - Intracellular fluid (ICF): Fluid inside the cells - Extracellular fluid (ECF): Fluid outside of the cells - Interstitial: Water surrounding the body’...

Med Surg Quiz 1 Chapter 6: Nursing Care of Patients with Fluid, Electrolyte, and Acid-Base Imbalances Fluid Balance - Intracellular fluid (ICF): Fluid inside the cells - Extracellular fluid (ECF): Fluid outside of the cells - Interstitial: Water surrounding the body’s cells and includes lymph - Intravascular: Blood plasma existing within arteries, veins, and capillaries. - Fluids and electrolytes move between the interstitial fluid and intravascular fluid. - Transcellular: Those in specific compartments of the body: CSF, digestive juices, and synovial fluid in joints. Control of Fluid Balance - Pressure sensors in the vascular system stimulate or inhibit the release of antidiuretic hormone (ADH) from the pituitary gland. - Antidiuretic hormone: Causes kidneys to retain fluid, if fluid pressure within the vascular system decreases, more ADH is released and water is retained. If fluid pressure increases, less ADH is released and the kidneys eliminate more water. Movement of Fluids and Electrolytes in the Body - Active Transport: Depends on presence of adequate cellular ATP for energy. - Common examples are sodium-potassium pumps located in cell membranes causing sodium to move out of the cells and potassium to move into the cells when needed. - Passive Transport: No energy is used specifically to move the substances. General body movements aid passive transport. - Diffusion: Movement of a substance from an area of higher concentration to an area of lower concentration - Works like a tea bag in hot water. - Filtration: Movement of both water and smaller molecules through a semipermeable membrane from an area of high pressure to an area of low pressure. - Filtration is promoted by hydrostatic pressure differences between areas (water pushing pressure). - Filtration is important for the movement of water, nutrients, and waste products in the capillaries. The capillaries are semipermeable and allow water and smaller substances to move from the vascular system to the interstitial fluid. - Osmosis: Movement of water from an area of lower substance concentration across a semipermeable membrane to an area of higher concentration.  - Osmotic pressure is the power to pull water toward an area of higher concentration. - Osmolarity: The concentration of substances in body fluids - Normal osmolarity of blood is 270-300 milliosmoles per liter (mOsm/L). - Another term for osmolarity is tonicity. - Fluids are classified as isotonic, hypotonic, or hypertonic - Isotonic: Fluid having the same osmolarity as blood - Stays with the blood - 0.9% normal saline used for IV therapy - Hypotonic: Fluid with lower osmolarity than blood - Water in solution leaves the blood and enters the cells - Hypertonic: higher concentration Exert greater osmotic pressure than blood - Water leaves the cells and enters the bloodstream and other ECF spaces. Fluid Gains and Losses - Gains: Through food and fluid - Losses: Sensible-measurable (person is aware, like urination) and Insensible- unmeasureable (occur without person recognizing the loss, like stool and respiration) Fluid Imbalances - Dehydration/Hypovolemia - Occurs when there is not enough fluid in the body, especially in the blood - Pathophysiology and Etiology: Most common form is loss of fluid in from the body, resulting in decreased blood volume. This decrease is referred to as hypovolemia. Hypovolemia occurs when a patient is hemorrhaging or when fluids from other parts of the body are lost. It can also occur when fluid moves from the intravascular space into the interstitial spaces, and is called third spacing - Prevention: Identifying high risk patients: older adults, infants, children, and any patient experiencing diarrhea, diuretic therapy, draining abscess or fistula, fever, GI suction, hemorrhage, ileostomy, long term NPO status, profuse diaphoresis, systemic infection, or vomiting. - Adequate hydration is another important intervention. - 30 mL/kg/day of fluids - Signs and Symptoms: Thirst; rapid, weak pulse; low blood pressure; dry skin and mucous membranes; skin tenting; decreased urine output; increased temperature. - Diagnostic Tests: Elevated urea nitrogen (BUN) and hematocrit. - Creatine - checks electrolyte levels 20 to 1 Is dehydrated. 50 to 1 severely dehydrated - Specific gravity of urine also increases as the kidneys attempt to retain water.  - Interventions: Monitor daily weight; monitor I&Os; increase fluid intake; treat underlying cause; use caution in elderly patients. - Patient Education: Signs and symptoms of dehydration and reporting them to the HCP; low sugar fluids through the day; fresh lemon in water to make it more appealing; need to replace fluid lost through sweating, vomiting, and diarrhea. - Fluid Excess/Overhydration/Hypervolemia - Too much fluid in the body; related to fluid excess in the bloodstream or dilution of electrolytes and RBCs. - Pathophysiology and Etiology: Most common result is hypervolemia where there is an excess of fluid in the interstitial space. Kidneys can compensate for mild to moderate hypervolemia but sometimes can’t keep up with excess fluid. - Poorly controlled IV therapy or excessive ingestion of water - Can occur secondary to excessive sodium intake, adrenal gland dysfunction, or use of corticosteroid drugs. - Can result in kidney failure, heart failure, and the syndrome of inappropriate ADH. - Prevention: Avoid excess fluid intake. Monitor patients receiving IV therapy. Also monitor fluid used for irrigations (gastric lavage) and be sure that excess amount of fluid is not being absorbed (enemas). - Signs and Symptoms: Bounding pulse; elevated BP; respiratory changes; edema; polyuria; weight gain; heart failure. - Complications: Bounding pulse; elevated BP; respiratory changes; edema; polyuria; weight gain; heart failure. - Diagnostic Tests: BUN creatin and hematocrit levels decrease; plasma content is increased; specific gravity diminishes with polyuria. - Interventions: Monitor weight and urine output; place is fowler’s position; administer oxygen; administer diuretics; restrict fluid and sodium intake. - Patient Education: Reinforce sodium restrictions; encourage high potassium foods if diuretic is prescribed; reinforce signs and symptoms of fluid excess and monitoring daily weights. Electrolyte Imbalances: - Natural minerals in food become electrolytes or ions in the body through digestion and metabolism - Measure in milliequivalents per liter (mEq/L) - Either cations or anions: - Cations: Carry a positive electrical charge - Anions: Carry a negative electrical charge - Serum electrolytes are measured regularly. - Should be checking patients for imbalances based on: changed mental status (increased irritability or decreased responsiveness) or muscle function. Sodium (Na+) Imbalances: - Normal level: 135-145 mEq/L - Major cation in the blood and helps maintain serum osmolarity. - Sodium imbalances are associated with fluid imbalance  - Important for cell function, especially in CNS - Food Sources of Sodium: Pizza; canned vegetables; canned soups; salty snacks; prepared foods. - Hyponatremia - Serum sodium level is lover than 135 mEq/L - Pathophysiology: Inadequate sodium intake or excessive sodium loss from the body. Sodium may also get trapped in the interstitial spaces due to third spacing, where it becomes trapped and useless. Also decreases when plasma volume increases during fluid excess, causing a dilutional effect - Risk Factors: High fevers; strenuous exercise or physical labor especially in heat; older patients; NPO patients; GI suction; use of diuretics; syndrome of inappropriate ADH; excessive ingestion of hypotonic fluids; freshwater near-drowning; decreased aldosterone. - Signs and symptoms: Fluid excess of deficit; mental status changes; weakness; nausea and vomiting - Complications: Seizures; respiratory arrest; coma; death; pulmonary edema - Diagnostic Tests: serum sodium level; serum chloride levels - Interventions: Monitor I&Os; monitor weight; restrict fluids; administer diuretics/steroids. - Hypernatremia - Serum sodium level above 145 mEq/L - Pathophysiology: May be an actual increase or relative increase. In an actual increase the patient receives too much sodium or is unable to excrete sodium, as in kidney failure. In a relative increase, the amount of sodium does not change, but the amount of fluid in the intravascular space decreases and the percentage of sodium is increased in relation to the amount of plasma. - Risk Factors: Chronic illness; intake of high sodium foods - Signs and Symptoms: Thirst; mental status changes; seizures; muscle weakness; respiratory compromise. - Complications: Coma; respiratory arrest;; weakening of skeletal muscles. - Diagnostic Tests: Serum sodium level; If fluid imbalance occurs, BUN, hematocrit, and urine-specific gravity tests are also affected. - Interventions: Treat fluid imbalance first; monitor I&Os; monitor weight; administer diuretics; restrict dietary sodium; treat cause. Potassium (K+) Imbalances: - Normal level: 3.5-5.3 mEq/L - Small changes in value can cause major changes in the body - Important for cardiac muscle, skeletal muscle, and smooth muscle function - Body compensates for losses by moving potassium from the cells into the bloodstream. - Foods containing Potassium: Sweet potatoes; beet greens; potatoes; yogurt; prune juice; bananas; orange juice; avocados. - Hypokalemia - Most commonly occurring imbalance. - Serum potassium level below 3.5 mEq/L  - Pathophysiology: Inadequate intake of potassium or excessive loss through the kidneys. Most commonly occurs as a result of medications: potassium-wasting diuretics and corticosteroids. - Risk Factors: Medications: potassium-wasting diuretics and corticosteroids; severe vomiting, diarrhea, and prolonged GI suction; major surgery and hemorrhage. - Signs and Symptoms: muscle weakness; shallow respirations; mental status changes; cardiac arrhythmia and arrest. - Diagnostic Tests: Serum potassium level; ECG may show arrhythmias associated with deficit; - pt may have metabolic alkalosis and commonly accompanies hypokalemia. - In metabolic alkalosis, serum pH of blood increases so that blood is more alkaline - Interventions: Treat underlying cause; offer potassium-rich foods; administer potassiumreplacement - Patient Teaching: Signs and symptoms to report; Self administration of supplement. - Hyperkalemia - Serum potassium level exceeds 5.3 mEq/L - Rare in a person with healthy kidneys - Pathophysiology: May result from actual increase in the amount of total body potassium or from movement of intracellular potassium into the blood which is common in massive tissue trauma and metabolic acidosis commonly seen with uncontrolled diabetes mellitus. - Risk Factors: Overuse of potassium based salt substitutes or excessive intake of oral or IV potassium supplements; use of potassium-sparing diuretics; kidney failure patients; patients with uncontrolled diabetes. - Signs and Symptoms: Muscle twitching and cramps, later muscle weakness; diarrhea, low blood pressure; cardiac arrhythmia and arrest - Diagnostic Tests: Serum potassium level; ECG changes; serum pH - Interventions: Limit dietary potassium; hold potassium supplements; Administer medications as ordered: potassium-losing diuretics, kayexalate, and insulin with glucose. - Patient teaching: Box 6.4; Teach how to take and monitor potassium supplements. Calcium (Ca++) Imbalances - Primarily stored in bones and teeth but a small amount is found in ECF - Normal value is 8.2-10.2 mg/dL or 2.1 or 2.6 mmol/L - Minimal changes have major negative effects in the body - Needed for proper function of excitable tissues, especially cardiac muscle - Food Sources of Calcium: Fortified cereals; canned salmon; spinach; yogurt; cheese; milk - Hypocalcemia  - Serum calcium level falls below 8.2 mg/dL or 2.1 mmol/L - Pathophysiology: Body loses more calcium than it can replace from the intestines or bones. - Risk Factors: Postmenopausal women; lactose intolerant patients; adolescents; elderly; pregnant and lactating women; those that have chronic disease; inflammatory bowel diseases; thyroid removal patients; patients with hyperphosphatemia. - Signs and symptoms: Mental status changes; hyperactive deep tendon reflexes (DTRs); diarrhea; cardiac arrhythmia and arrest - Trousseau sign: Inflate a BP cuff around patients upper arm for 1-4 minutes. In a patient with hypocalcemia, the hand and fingers become spastic and go into palmar flexion. - More specific for hypocalcemia - Chvostek sign: Tap the face just below the and in front of the ear. Facial twitching on that side of the face indicates a positive test. - Chvostek sign: Check the cheek. - Complications: Tetany: continuous muscle contraction; laryngospasm that will stop air from entering lungs; seizures; respiratory failure; or cardiac failure. - Diagnostic Tests: Low serum calcium and abnormal ECG - Interventions: Treat cause; increase dietary calcium; Administer medications as ordered: IV calcium gluconate, oral calcium supplements, aluminum hydroxide to bind phosphate. - Hypercalcemia - Serum levels above 10.2 mg/dL or 2.6 mmol/L - Pathophysiology: Calcium levels in blood increase due to an imbalance between calcium entering the bloodstream and calcium being excreted in urine or deposited in bones. Can be caused by parathyroid hormone (PTH) excess; parathyroid hormone-related protein excess; vitamin D excess; bone metastases; immobilization. - Risk Factors: Patients taking certain medications or supplements; cancer patients; immobile patients; dehydration; chronic kidney disease/failure; overactive thyroid gland; Paget disease; TB; genetic factors. - Signs and Symptoms: Increased heart rate and blood pressure; skeletal muscle weakness; decreased gastrointestinal motility. - Complications: Kidney or urinary calculi; respiratory failure caused by profound muscle weakness; heart failure caused by arrhythmias. - Interventions: Administer fluids; administer medications as ordered: furosemide (Lasix), pamidronate, zoledronic acid, calcitonin; and hemodialysis. Magnesium (Mg+) Imbalances - Magnesium and calcium work together for the proper functioning of excitable cells, such as cardiac muscle and nerve cells - Imbalance of magnesium is followed by imbalance of calcium - Normal levels are 1.6-2.2 mg/dL - Hypomagnesemia  -Serum magnesium level below 1.6 mEq/L -Pathophysiology: Decreased intake or excessive loss of magnesium. -Risk Factors: Malnutrition or starvation diets; Patients with severe diarrhea or Crohn’s disease; alcoholism; osmotic diuretics; aminoglycosides; and some anticancer agents - Signs and Symptoms: Positive Trousseau sign; positive Chvostek sign; cardiac arrhythmia and arrest - Interventions: Treat underlying cause; administer magnesium replacement. - Hypermagnesemia - Serum Magnesium level increases above 2.2 mEq/L - Pathophysiology: Most common cause is increased intake coupled with decreased renal excretion caused by kidney failure. - Risk Factors: Kidney disease; excessive intake; intestinal issues - Signs and Symptoms: Hypotension; lethargy; skeletal muscle weakness; respiratory failure; cardiac arrhythmias and arrest. - Interventions: IV fluids; Medications as ordered: loop diuretics (furosemide) and dialysis. Chapter 10: Nursing Care of Patients in Pain Definition of Pain: Pain is “an unpleasant sensory and emotional experience associated with, or resembling that associated with, or resembling that associated with, actual or potential tissue damage. - Can be acute (6 months or less) or chronic (6 months or more) - Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does. - Pain is a personal experience shaped by events over one’s life course - The patient’s self-report of pain is the gold standard in pain assessment - Pain can negatively affect a person physically, emotionally, socially, spiritually, and financially. Acute Pain - Generally lasts less that 3 months but may last up to 6 months or longer depending on the cause - Symptoms lessen over time - Prompts an inflammatory response - Signs and symptoms are short-term, objective, physical (like increased heart rate) Chronic Pain - Lasts longer than the anticipated time of healing. - Longer than 6 months - Signs and symptoms persistent - Patients may not always appear to be in pain. - Can cause an increase in depression or in negative behaviors in patients with dementia, autism, schizophrenia, or other psychiatric conditions. Suffering  - Feelings of continuous distress - Often associated with chronic pain - Can cause emotional and spiritual distress - May be relieved with belief that comfort can be achieved - Spiritual coping may be a source of comfort - In addition to or instead of medication based on culture - May engage in religious practices such as prayer or meditation. - May be nonreligious and include self-reflection or connecting socially with others to affirm meaning and purpose in life. Risks of Uncontrolled Pain - Body produces a stress response that causes harmful substances to be released from injured tissue - Reactions - Breakdown of tissue - Increased metabolic rate - Impaired immune function - Negative emotions - Prevents patient from participating in self-care activities - Lack of movement due to pain leads to pulmonary secretions and pneumonia - Deep breathing, coughing, and walking Cultural Considerations - Identify key areas of cultural expression - Language - Listen for words or nonverbal cues that indicate discomfort - Pain assessment scale used - Allow patients to answer questions - Family engagement - Observe family involvement and teach them how to monitor discomfort - Help with relaxation and distraction - Treatment preferences - How they treat pain at home and what they feel they need to help with pain - Incorporate home remedies - Assess each patient’s pain experience - Remember ethical principles - Do not make assumptions about culture Who is Responsible for Pain Management: - Patient is center of health-care team - Entries health-care team is responsible for pain management - Regulatory bodies review pain management practices - The Joint Commission - Centers for Medicare and Medicaid Services - State Licensing bodies - Agency for Healthcare Research and Quality Opioid Addiction - Tolerance - Biological adaptation to long-term use of a drug - Less effective: More of a drug to provide relief - Physical dependence: - Normal psychological response most people experience after a week or more of opioid use - Patient may experience withdrawal if abruptly stopped - Addiction/Psychological dependence: - Chronic disease of brain influenced by genetics, environment, and life experiences causing compulsive pursuit of a substance or behavior to obtain reward/relief of craving - Poor control of drug use - Reduced recognition of problem behaviors - Pseudo-addiction - Patients receiving too low of a dose of medication to control pain - Addiction goes away when pain is managed Pain Transmission - Transduction: Initiation of stimulus and conversion into electrical impulse at time of injury - Transmission: Moving painful message from peripheral nerve ending to the spine/brain - Perception: Actually feeling pain; hypothalamus activates, controlling emotional input and generates goal-directed behavior - Modulation: Body’s attempt to interrupt pain by sending endorphins to inhibit pain impulses Neurotransmitters: Interrupt pain and inhibit pain impulses - Prostaglandins - Bradykinin - Serotonin - Substance P - Endorphins - Enkephalins Mechanisms of Pain Transmission - Nociceptive pain: Somatic and visceral pain - Tissue damage - Neuropathic pain - Nerve damage Referred Pain - Felt in body away from source Pain Treatment - Analgesics - Opioid: Bind to receptors in brain, inhibiting perception of pain - Nonopioid: NSAIDs - Adjuvant” Categories of meds originally used to treat something other than pain - Equianalgesic: Equal analgesia  - Estimated dosage to provide same amount of pain relief - Morphine is the standard which all other analgesics are compared to. - Opioid Antagonists (Stimulators): Blockers; Block receptors: Narcan - Other treatments: - Placebos: Not used unless in clinical trial and consent is given - Nonpharmacological methods - Cognitive/Behavior interventions: education, relaxation, guided imagery, distraction, and biofeedback. Placebos - Administer inactive substitutes for analgesics - Not justified in the treatment of pain - Only used in research with informed consent - Analgesic Routes - Oral - Rectal - Inhalation - Transdermal (ID) - Intramuscular (IM) - IV: - Patient-controlled analgesia (PCA) - Subcutaneous (SUBQ) - Intraspinal The LPN will: - Maintain pain control devices (epidural, PCA, peripheral nerve catheter) - Monitor O2 levels and provide oxygen if indicated - Provide non pharmacological measures for pain relief (e.g. imagery, massage, repositioning) - Evaluate pain using standardized rating scales - Evaluate client response to medication (adverse reactions, interactions, therapeutic effects) Nonpharmacological Therapies: - Cognitive-behavioral - Education - Relaxation - Imagery - Distraction - Biofeedback - Physical Agents: - Heat - Cold - Massage/vibration - Exercise - Immobilization - Transcutaneous Electrical Nerve Stimulation (TENS) Pain Assessment - WHAT'S UP? - Where is the pain? - How does the pain feel? - Aggravating and alleviating factors? - Timing - Severity (on 0-10 scale) - Face scale if can’t cognitively label pain - Useful other data - Vital signs, facial expressions, and nonverbal cues - Patient’s perception Pain Scales - Be able to explain the pain scale so the pt can relay pain - Describe pain - Faces - For kids or pt’s that can’t speak Pain Assessment in Advanced Dementia (PAINAD) - Dementia patients - When patients can’t tell you about pain Level of Sedation Scale - After administering pain meds Patient Education: - Analgesic side effects - Fatigue - Constipation - Stool softeners/move around after surgery - NSAIDs - Opioids - Adverse effects - Monitor vital signs, respiratory rate - Assess for decrease in respirations and heart rate - Can’t give pain meds when vitals depressed - Monitor total acetaminophen doses - Can only be given a certain amount per day Pain Education - Dose frequency and duration - Take medication on a schedule with chronic pain to improve mobility and function - Take medication consistently with pain to keep patient’s mobile - Educate patients about pain med schedule - Suggest other medications if patient doesn’t want IV medications - Interactions - Be careful with pain medications and muscle relaxants - Could sedate patients or react with each other - Always have to tell patient what you’re giving  - Do not mix drugs or alcohol with pain medications - Educate patients about meds Safety - All pain medications should be kept out of reach of children - Opioids should be locked away or at least not easily accessed by other members of the household visitors - Ensure proper disposal when discontinued Chapter 12: Care of Patients Having Surgery Surgical procedures are named by: the involved organ, body part, or location; the suffix describes what is done during the procedure. TYPES AND PHASES OF SURGERY: Laser, scope, and robotic technologies reduce invasive mess of procedures - Less damaging; faster, less painful recovery. Minimally invasive surgeries are called keyhole surgery. - Endoscope and thoracoscope Robot-assisted surgeries use two robotic arms that the surgeon controls to cut, suction, or suture. Three phases in the surgical process: Preoperative, intraoperative, and postoperative. Perioperative refers to all three phases. PREOPERATIVE PHASE: - Assist in data collection and contribute to plan of care - Reinforce teaching and instructions given by surgeon and RN - Provide emotional and psychological support. FACTORS INFLUENCING SURGICAL OUTCOMES - Identify and implement actions to reduce surgical risks. - Prehabilitation: planned Preoperative, functional, physical, and lifestyle preparation to help the patient achieve the best possible surgery and recovery outcome. - Controlling anxiety, preventing deconditioning after surgery through exercise preoperatively, providing nutritional support, and weight loss counseling, or avoiding smoking, drinking, or recreational drug use. - AGE - Longer to recover from anesthesia due to decreased metabolism - Decreased ability to compensate from stress of surgery due to declining body systems/organs - Perioperative interventions focus on reducing complications - CHRONIC DISEASE: - Increase surgical risk; clearance needed from Health-care Provider  - EMOTIONAL RESPONSES - Allow patients to discuss concerns and assist them in coping with their feelings. - If fear is extreme, let the surgeon know so the surgery can be reevaluated or postponed. - Anesthesiologists should discuss all anesthesia related fears with the patient. - Guided imagery, focused breathing, and music as well as analgesics can relieve pain. Pain management plans should be discussed with patients before surgery. - NUTRITION - Well-nourished to heal from surgery - Higher levels of protein (tissue repair and healing), Vitamin C (collagen formation), and zinc (tissue growth and skin integrity) are required. - Obese patients may have delayed healing of wound dehiscence. - Patients with diabetes or who are malnourished may experience infection or delayed wound healing. - Screening for and correcting nutritional deficiencies before surgery lessens the impact of the metabolic stress of surgery so patients recover sooner. - SMOKING AND ALCOHOL AND/OR DRUG ABUSE - Smoking thickens and increases the amount of lung secretions, reducing cillia’s ability to remove secretions. - Quit smoking at least 24 hours before surgery - Those with chronic lung disorders should quit smoking 4 weeks before surgery. - Increases actions of lungs’ defense mechanisms, makes more hemoglobin available to carry oxygen, and improves wound healing. - Long term alcohol and drug abuse causes nutritional deficiencies and liver damage. - Can create bleeding problems, fluid volume imbalances, and medication metabolism alterations - Can interact with drugs during surgery PREADMISSION SURGICAL PATIENT ASSESSMENT: - Non Emergent patients may have an assessment up to 30 days beforehand. - Interview with anesthesiologist or someone under direction of anesthesiologist. - Health history; identification of risk factors; patient and family teaching; discharge planning; necessary referrals to social workers, support groups, and educational programs - Problems with anesthesia or malignant hyperthermia are identified - Preoperative diagnostic testing based on age, medical history, data collection findings, and agency protocols. - Urine or serum pregnancy test for female patients of childbearing age - Inquire about advanced directive and durable power of attorney for patient records PREOPERATIVE TEACHING PREOPERATIVE ROUTINES: Teaching for preoperative routines: - Date/time of surgery  - Length of stay - Clothing to wear and items to leave at home - Recovery after surgery - Family information (waiting area and communication info) - Discharge PREOPERATIVE INSTRUCTIONS AND PREPARATIONS: - Special preps explained to patients: - Bathing or skin preps to reduce infection - Nasal cultures for bacteria - Fasting time frames for food/liquid intake - Medications to be taken before surgery - Brushing teeth without swallowing - Postoperative care instructions given before the procedure so the patient is alert and has time to practice self care exercises. - How to report pain level with pain scale - Pain relief methods and routes explained to patient - Anticipated dressings, casts, tubes, and special equipment described and demonstrated. - Post Op exercises that decrease complications are taught with return demonstrations. - Deep breathing and coughing; use of incentive spirometry; leg exercises; turning; and how to get out of bed. DATA COLLECTION HEALTH HISTORY: - Patient data collected on admission - Ensure patient is using all assistive devices to enhance communication - All medications (OTC, prescription, and recreational drugs) are reviewed. - May stop anticoagulants or NSAIDs several days before surgery. - Cannot stop steroids abruptly so a parenteral route is ordered. - Insulin instructions given - Monitoring every 4 hours after admission - Patients are asked about their use of alcohol and recreational drugs - Discuss possible interactions PHYSICAL ASSESSMENT - Establishes baseline and identifies risk factors - Report cough, cold, fever to surgeon - Document dentures, bridges, capped and missing teeth - Can become dislodged during endotracheal intubation NURSING DIAGNOSES, PLANNING, AND IMPLEMENTATION - Inform patient about procedures and surgical routines to reduce fear - Allow patient to express concerns to allow inaccurate information to be corrected - Ask if a patient would like a referral to a chaplain or social worker to discuss anxiety and fear.  - Identify knowledge deficiencies with patients and family or caregivers to provide appropriate information. - Ask the patient’s preferred learning method and use a variety of teaching methods. - Reinforce preoperative information and new information to empower patients to participate in their own care. - Document teaching reinforcements and patient’s understanding and continued learning needs as evidence of teaching and patient’s understanding. EVALUATION - Goal is to decrease anxiety and increase knowledge. PREOPERATIVE CONSENT - Protect patient from unauthorized procedures - Protect those involved in the procedure - Valid for 30 days and can be withdrawn at any time before the procedure. - Involves three elements: - Surgeon explains the diagnosis, proposed treatment, who will perform it, likely outcomes, possible risks/complications, alternative treatments, and the prognosis without treatment. The surgeon must be contacted for further explanation, the nurse cannot provide this information. - The consent must be signed before analgesics or sedatives are given. Patients must demonstrate to a witness that they are informed and understand the surgery. - Consent must be voluntary. - May have to sign as witness on the consent form. Must verify all above elements were achieved. - Patients cannot give consent if they are unconscious, mentally incompetent, under analgesics or meds that alter nervous system function, or minors. - If time does not permit obtaining consent, treatment must be life-saving or avoiding serious harm. PREOPERATIVE PREPARATION CHECKLIST Completed by nurse before patient is transported to surgery: - ID band placed on the patient. Proper clothing/gown is worn. - Vital signs taken and recorded as a baseline for patient - Makeup, nail polish, and artificial nails are removed for monitoring of oxygenation status during the procedure. - Removal of hairpins, wigs, and jewelry. Rings are allowed to be taped to the patient's finger if they are on the non operative side. Fingers may swell on the operative side. - Dentures, contact lenses, and prostheses are removed to prevent injury. - Glasses and hearing aids go with the patients to surgery if they need them to communicate. - All orders, test results, consents, and history and physical are reviewed for completion and documented on the checklist. - Patient’s valuables are locked up and documented - Anti Embolism devices applied if ordered - Patients are asked to use the restroom before sedation to prevent injury to the bladder. PREOPERATIVE MEDICATIONS Given at time ordered or on call to surgery. Bed rails and assistance for patients under sedatives or analgesics. TRANSFER TO SURGERY DEPARTMENT Inhaler medications transferred with patients. Family members can accompany patients during transfer. POST-TRANSFER TO SURGERY DEPARTMENT Prepare room and equipment to be ready when patient returns from PACU PATIENT ARRIVAL IN SURGERY DEPARTMENT - Greet patients and complete a comprehensive surgical checklist. - Verify patient name; allergies; surgeon performing surgery; items on preoperative checklist: informed consent; surgical procedure (correct site); medical history. - Answer questions to alleviate anxiety. - Operative site marked and confirmed by patient. - Prophylactic antibiotics give 60 to 120 minutes before incision is made to reduce surgical infections. - Before entering OR, patients should be told what to expect. - Cold; extra blankets can be given - A lot of equipment and bright lights - Several members of the health care team will introduce themselves and questions can be asked. - Surgeon will greet you - Safety checklist will be performed PREOPERATIVE WARMING Warming a patient's skin with a preoperative warming device for 30 minutes before anesthesia is helpful to maintain normal body temperature and reduce intraoperative hyperthermia. INTRAOPERATIVE PHASE - Patient transferred to operating table. - Surgical asepsis technique used - Controlled temperature and humidity of room - LPN may assist with maintaining sterile field - Safety checklist performed - Developed with pre admission assessment data - Timeout taken to verify all patient and surgical information to prevent mistakes. - Monitoring equipment applied and patient positioned to prevent pressure points from causing nerve or tissue damage. - Needed tubes (NG, catheter) are inserted. - Body hair removal with electric razor if needed but usually avoided - Skin prep: povidone-iodine, circular motion, inner to outer. ANESTHESIA: GENERAL ANESTHESIA - Causes patient to lose all consciousness  - Can be used when patients are anxious about local anesthesia, unable to cooperate, or impaired cognitive function. - IV AGENTS: - Induction: Period when anesthesia is first given until full anesthesia is reached. - Only last a few minutes and used with inhalation agents. - After induction, the patient is intubated. - INHALATION AGENTS: - Maintain anesthesia during surgery; used through mechanical ventilation - COMPLICATIONS - Side effects are brief: nausea, vomiting, confusion, sore throat, and shivering. - Serious complications are rare. Include: respiratory distress, malignant hyperthermia, and more commonly in older adults, temporary delirium, cognitive dysfunction. - Irritation to respiratory tract; laryngospasm, laryngeal edema, or injury to vocal cords. - Closely monitor the airway and be prepared to provide respiratory support. - ADJUNCT AGENTS - Adjunct: Medication used with primary anesthetic agent - Opiods to control pain; muscle relaxers to avoid nausea and vomiting; sedatives to supplement anesthesia. - LOCAL OR REGIONAL ANESTHETIC - Selected for patients that want to be awake, are not anxious, can tolerate the local agent, and are not required to be unconscious or have relaxed muscles. - Can be placed directly on surgical site to numb a small area - Bier block: placing tourniquet on the extremity to remove the blood and then injecting local anesthesia. - Field block is a series of injections surrounding the surgical area. - SPINAL AND EPIDURAL BLOCKS - Spinal Block: Injection of local agent into subarachnoid space - Epidural block: local agent injected into epidural space - Mainly for lower extremity, lower abdominal, or childbirth. - Motor and sensory function are blocked - Hypotension results from blockade; cardiac output is reduced; respiratory depression results if the block travels too far upwards - Legs feel heavy and numb - Reassure patients that the block will wear off and they will return to normal - COMPLICATIONS - Back pain; urinary retention; hematoma; nerve damage; postural puncture headache with regional anesthesia. - Headache may occur from leakage of CSF from needle puncture hole. Pressure is released on the brain and spinal cord and a low-pressure headache occurs.  - Worsens with sitting or standing - Nausea, dizziness, tinnitus, and vision disturbances may be present. - Headache resolves in 7 to 10 days - Blood patch can relieve symptoms PROCEDURAL SEDATION AND ANALGESIA - Purposeful, minimal sedation. Does not cause the complete loss of consciousness. - Patient remains in control of own airway - Propofol, ketamine, midazolam, and fentanyl or morphine given to produce sedation - Used based on procedure; patient’s general health; patient or physician preference. - Can be given by anesthesia providers or specially trained RN - NPO 6 hours before procedure - Clear liquids allowed up to 2 hours before procedure - Continuous ECG applied and oxygen saturation monitored. - Vital signs taken every five minutes - Emergency equipment on standby - After procedure, patient monitored every 15 minutes - Side effects include: nausea, drowsiness, and headache. - Patients ready for discharge when vital signs return to baseline and are stable, oral fluids are retained, patients can safely ambulate, and voiding has occurred. - Written and oral discharge teaching given to patients and the person they are being discharged to. - Both must sign instructions - Adult must drive patient home and provide safe environment - Patients can not drive, operate machinery or sign legal documents for 24 hours. TRANSFER FROM SURGERY - Patient is normothermic upon transfer from surgery - After local anesthetic, patients can return directly to the nursing unit but must go to PACU after general and spinal anesthesia. - Patient never left alone; safety is important concern - Ensuring airway and preventing falls are priorities. POSTOPERATIVE PHASE Begins when a patient is admitted to PACU or nursing unit. Ends with patient postoperative evaluation in the surgeon's office. ADMISSION TO PERIANESTHESIA CARE UNIT PACU nurse responsibilities: - Airway maintenance - Vital signs every 5 to 15 minutes - Body systems assessment including surgical site - Patient Safety - Monitoring anesthetic effects - Pain management - Accurate I&O’s - Identifying PACU discharge readiness  - Documentation - Bedside hand-off report to receiving nurse - Includes: name; allergies; procedure; type of anesthesia; status; complications; oxygen; dressing/drains/equipment; medications; post op orders; pertinent history; family; opportunity to ask questions NURSING PROCESS FOR PACU PATIENTS RESPIRATORY FUNCTION: - DATA COLLECTION: - Ensure patient maintains has a patent airway - Use jaw-thrust method to manually open patient’s airway - Maintain oxygen therapy if ordered - Encourage deep breathing - Report respiratory depression - Position patient on side to protect airway until fully awake - Use suction equipment as needed - EVALUATION: - Goal for ineffective airway clearance and aspiration risk is achieved if the patient's airway remains patent and lung sounds remain clear. - Goal for an ineffective breathing pattern is met if the patient's respiratory rate is within normal limits, no dyspnea is reported, and ABGs are within normal limits. CARDIOVASCULAR FUNCTION DATA COLLECTION: - Can include hypotension; arrhythmias; hypertension. - Data collection includes heart rate, blood pressure, ECG, and skin temp, color, and moistness. - Vital signs compared with baseline readings to determine status - Tachycardia; hypotension; pale skin color; cool, clammy skin; and decreased urine output indicated hypovolemic shock. NURSING DIAGNOSES, PLANNING, AND IMPLEMENTATION - Monitor dressings, incisions, and drains for color and amount of drainage to detect fluid loss - Monitor I&O to detect imbalances - Maintain IV fluids at ordered rate to replace lost fluid and avoid fluid overload. EVALUATION: - Goal is met if vital signs and urine output are within normal limits. PAIN DATA COLLECTION - Rate presence of pain using pain scale - Document location and characteristics of pain - If patient is not fully awake, monitor vital signs and nonverbal indications of pain - Nonverbal indicators: abnormal vital signs, grimacing, moaning, restlessness, rubbing, or pulling at specific areas or equipment. NEUROLOGIC FUNCTION - May wake up agitated or behaving irrationally for a short time. Called emergent delirium. - Prevent injury by providing safety measures: side rails; restraints; protecting IV sites and ET tubes in place. - Confused patients may wake up agitated or frightened - Watch for nonverbal pain cues. - Data collection involves level of consciousness; orientation to person, place, time, and event; pupil size and reaction to light; and motor and sensory function. FAMILY VISITATION - Visiting helps patients and family - Educate family about expectations for visitation - Ensure confidentiality DISCHARGE FROM PACU - Length of stay for a stable patient is 1 hour - Postanesthesia Recovery Scale used to score patient’s readiness to be discharged - Scale rates respiration; oxygen saturation; level of consciousness; activity; and circulation. - If patient is unstable they are transferred to the ICU TRANSFER TO THE NURSING UNIT - Hand-off report done between discharging and receiving nurse - Transferred on bed with tubes and poles secured - Education to prevent falls: - Bed in lowest position with wheels locked; side rails raised; call button within reach - Instruct patient on how to call for assistance with ambulation - Assistance by one or two people given to help patient; encourage patient to dangle to prevent dizziness NURSING PROCESS FOR POSTOPERATIVE PATIENTS - Head to toe assessment performed after transfer to unit - Respiratory status, vital signs, LOC, surgical site, dressings, and pain level noted. - IV site patency and IV solution and infusion rate are monitored. - Chest tubes and NG tubes hooked to suction as ordered - Interventions to promote recovery implemented: - Monitoring for complications and providing post-op care. - Complications place patients at risk for delayed surgical recovery. - Respiratory function - Cardiac function - Postoperative pain - Urinary function - Surgical wound care - Gastrointestinal function POSTOPERATIVE PATIENT DISCHARGE: AMBULATORY SURGERY DISCHARGE CRITERIA: - Usually 1 hour after surgery - Stable vitals, no bleeding, no nausea or vomiting, controlled pain that is not severe - May be required to void to discharge - Sit up without dizziness - Discharge by surgeon to responsible adult DISCHARGE INSTRUCTIONS: - Patient and responsible adult sign and understand instructions - Encourage rest for 24 to 48 hours - Dietary, fluid, activity, work restrictions will be ordered by the surgeon. - Anesthesia may alter thinking ability and energy levels. - Patients are taught wound care, medication information (including side effects), and complications to report to the surgeon. - Phone numbers for surgeon, facility, and emergency care are provided. - Patients are encouraged to set up follow up appointments with the surgeon. - Follow up call made by the nurse to the patient the next day to answer questions and check on the patient. INPATIENT SURGERY DISCHARGE CRITERIA: - Surgeon determines patient’s readiness for discharge - Complete data collection of patient is collected and documented before discharge DISCHARGE INSTRUCTIONS - Patients and families are taught wound care, medication information, and signs and symptoms of complications to report to the surgeon. - Special orders and follow up appointment guidelines still apply - Prescriptions are sent to the pharmacy for pick up - Home health referrals can be made by the case manager.