MS II Exam 2 Study Guide.docx

**Med-Surg II Exam 2 Study Guide** **Sensory** Visual cortex: in the occipital lobe Auditory cortex: in the temporal lobe **[Normal Retina]** - The retina is an extension of the optic nerve - Pinkish red color is healthy - Retina layers - Retinal Pigment Epithelium (RPE)...

**Med-Surg II Exam 2 Study Guide** **Sensory** Visual cortex: in the occipital lobe Auditory cortex: in the temporal lobe **[Normal Retina]** - The retina is an extension of the optic nerve - Pinkish red color is healthy - Retina layers - Retinal Pigment Epithelium (RPE) - Single layer of cells with many functions like absorption of light - Sensory Retina - Contains photoreceptor cells (rods & cones) - Rods are responsible for night & low light vision (found throughout the retina but absent in fovea) - Cones are essential for visual acuity, color discrimination & fine detail (found throughout the retina & greatest concentration in fovea) - Optic disc - Sharp with distinct outline - Round or oval - Yellow/orange to creamy pink in color - Retinal Vessels - 4 sets (paired vein & artery in each quadrant) - Arteries appear brighter red than veins - Vessels get smaller the further away they are from the optic disc - Distorted vessels are seen in patients with poorly managed diabetes, hypertension or even cytomegalovirus infections **[Strabismus vs. Nystagmus]** - Strabismus (lazy eye): deviation from perfect ocular alignment (eyes aren't straight) - Can be corrected with early treatment to align the eyes using glasses/bifocals, eye patch, or surgery - Nystagmus: involuntary oscillation of the eyeball **[Assessment & Evaluation of Vision ]** - Ocular history - Blurred vision? Duration? Symptoms? - Visual acuity - Snellen chart: distance - Rosenbaum pocket screener: near - Finger count or hand motion - Examination of eye structures **[Examination of Eye Structures]** - External - Irritation, inflammatory process, discharge, etc. - Eyelids & sclera - Pupils & pupillary response (use darkened room) - Note gaze & position of eyes & eyelids - Ptosis: congenital, aging, disease (like Myasthenia Gravis) - Assess extraocular movements (CN 3, 4, 6) - Internal - Fundus (retina, macula, fovea, optic disc, blood vessels) - Tonometry: risk for glaucoma - Assesses intraocular pressure - Should be 10 -- 21 mmHg **[Impaired Vision-Refractive Errors]** - Corrected by lenses with glasses/contacts for BCVA (best corrected visual acuity) - Impaired from shortened/elongated eyeball or irregularities with lens/sclera - Myopia longer eyeball nearsighted - Hyperopia shorter eyeball farsighted - Astigmatism: cornea or lens is irregularly shaped so that when light enters, there are multiple focal points & it causes blurry vision **[Snellen Chart]** - Assesses BCVA of distance - 20/20 is normal vision - The larger the denominator, the worse the vision - 20/200 you see at 20 feet what someone with normal vision can see 200 feet away - The smaller the denominator, the better the vision - 20/30 to 20/60 is near normal/mild vision loss - 20/70 to 20/160 is moderate visual impairment - 20/200 and on is legal blindness - Can see stop sign letters - 20/500 to 20/1000 is profound visual impairment - Red & green bars test for color discrimination (color blindness) **[Ophthalmic Medications]** - Ability of the eye to absorb medication is limited - Size of conjunctival sac - Corneal membrane barriers - Blood---ocular barriers - Tearing, blinking & drainage - Topical medications (drops & ointments) preferred because they - Are less invasive - Have fewest side effects (compared to oral meds) - Allow for self-administration - Topical anesthetics - Mydriatics (dilate) & cycloplegics (paralyze) - Contraindicated with narrow angles or shallow anterior chambers & in patients on monoamine oxidase inhibitors (ex: phenelzine) or tricyclic antidepressants (ex: imipramine) - Patients with glaucoma - MAOIs & TCAs affect CNS causing tachycardia, dizziness, hypertension can increase the risk of intraocular & optic nerve damage - Anti-infective medications - Antibiotic, antifungal, or antiviral products - Medications for glaucoma - Glaucoma occurs because there's an increase in intraocular pressure - Increase aqueous outflow or decrease aqueous production - May constrict the pupil; may affect ability to focus the lens of the eye; affects vision - May also produce systemic effects - Patients with glaucoma & hypertension taking meds can impact systemic BP - Anti-inflammatory drugs; corticosteroid suspensions - Side effects of long-term topical steroids: glaucoma, cataracts, increased risk of infection, impaired wound healing - High ICP may develop after corticosteroids are discontinued - To avoid these effects: NSAID therapy may be used as an alternative to steroid use A close-up of a chart Description automatically generated **[Low Vision & Blindness]** - Low vision - Visional impairment that requires devices & strategies to correct vision - BCVA of 20/70 up to 20/200 - Blindness - Range: BCVA 20/200 to no light perception - Impaired vision often is accompanied by functional impairment - Nursing assessment must include: - Functional ability & coping - Adaptation in emotional, physical & social areas **[Management of Low Vision & Blindness]** - Support coping strategies, grief processes & acceptance of visual loss - Strategies for adaptation to the environment - Placement of items in the room describe where objects are - "Clock method" for trays to describe items on the plate - Communication strategies - Collaboration with low-vision specialist, occupational therapist or other resources - Braille or other methods for reading & communication - Service animals When assisting a pt who is legally blind, which intervention [would not] be appropriate? A. Allow the pt to hold the nurse's arm above the elbow while walking a step behind when ambulating to bathroom B. Describe food items on meal tray using clock terms C. **Offer to feed the pt all meals** a. **No, we should encourage independence** D. Remove obstacles in room and describe furniture placement **[Glaucoma]** - A condition in which damage to the optic nerve is related to increased intraocular pressure (IOP) caused by congestion of the aqueous humor - Aqueous humor production & drainage are not in balance aqueous humor builds up in eye loss of peripheral vision - Normal IOP: 10 -- 21 mmHg - Increased IOP irreversible mechanical or ischemic damage to the optic nerve - Types: - Wide angle - Narrow angle - Risk factors: - Cardiovascular disease, diabetes, older age, previous eye trauma - "Silent thief"; unaware of the condition until there is significant vision loss; peripheral vision loss, blurring, halos, difficulty focusing, difficulty adjusting eyes to low lighting - May also have aching or discomfort around eyes or headache **[Glaucoma Types]** - Wide Angle (most common) - Fluid does not drain properly - Slow increase of IOP slow optic nerve deterioration gradual vision loss - Outflow resistance at trabecular framework - Slower development over time - Narrow Angle **(EMERGENCY)** - Blockage of fluid at base of interior angle between iris & cornea - IOP increases rapidly - Permanent vision loss if IOP is untreated for more than 24-48 hours - Outflow resistance at pupil - Increased pressure from posterior chamber produces narrow angle of iris, blocking trabecular framework **[Glaucoma -- Diagnostic Studies]** - Tonometry to assess IOP - Ophthalmoscopy to inspect the optic nerve disc - Pallor of optic nerve: lack of blood supply - Cupping of optic disc: exaggerating bending of blood vessels across the optic disc normal cup appears as a basin - Caused by gradual loss of blood supply - Central visual field testing - Assess peripheral vision loss **[Glaucoma -- Treatment]** - Goal is to prevent further optic nerve damage - Maintain IOP within range unlikely to cause damage - Pharmacologic therapy - Miotics (pilocarpine), beta blockers (timoptic), Alpha2-agonists, carbonic anhydrase inhibitors, prostaglandins - Provide education regarding use & effects of meds - Laser procedures, surgery - Provide support & interventions to aid the patient in adjusting to vision loss or potential vision loss A chart with text on it Description automatically generated **[Cataracts]** - An opacity or cloudiness of the lens - Increased incidence with aging; by age 80 years, more than half of all Americans have cataracts - Blurry vision, dimmer surroundings - A leading cause of disability in the US - Age: risk factor - Three types - Traumatic - Congenital - Senile cataract **[Cataract Manifestations]** - Painless, blurry vision, surroundings dimmer - Sensitivity to glare - Reduced visual acuity - Other effects include myopic shift, astigmatism, diplopia (double vision) & color shifts, including brunescent (color value shift to yellow brown) - Diagnostic findings include decreased visual acuity & opacity of the lens by ophthalmoscope, slit lamp, or inspection **[Cataracts -- Surgical Management]** - If reduced vision does not interfere with normal activities, surgery is not needed - Surgery is performed on an outpatient basis with local anesthesia - Surgery usually takes less than 1 hour & patients are discharged soon afterward - Complications are rare but may be significant - Inflammation, infection, pain, light sensitivity, macular edema (swelling of the central retina), ocular hypertension **[Cataract Surgery -- Nursing Management]** - Usual preoperative care for ambulatory surgery - Dilating eye drops or other medications as ordered - Postoperative care - Eye drops - Patient education: written & verbal discharge instructions - Meds - Sleep on opposite side - IOP (sneezes, coughing) - Eye shield to wear at night - Instruct patient to call physician **immediately** if: - Vision changes, continuous flashing lights appear (photopsia), redness, swelling, or pain increase, type & amount of drainage increases, or significant pain is not relieved by acetaminophen **[Cataract Surgery -- Discharge Instructions]** - Avoid lying on the side of the affected eye the night after surgery - Keep activity light (e.g., walking, reading, watching television) - Resume the following activities only as directed by the ophthalmologist: driving, sexual activity, unusually strenuous activity - Avoid lifting, pushing, or pulling objects heavier than 15 lbs. - Avoid bending or stooping for an extended period - Be careful when climbing & descending stairs - Sneezing, if necessary, should not be held in, it should be done with an open mouth - When to notify a provider/go to the ED/call 911 **[Retinal Detachment]** - Separation of the sensory retina & the RPE (retinal pigment epithelium) - Manifestations: sensation of a shade or curtain coming across the vision of one eye, bright flashing lights, sudden onset of floaters - Diagnostic studies: assess visual acuity, assessment of retina by indirect ophthalmoscope, slit lamp, stereo fundus photography, & fluorescein angiography; tomography & ultrasonography may also be used  **[Retinal Detachment -- Surgical Treatment]** - Scleral buckle - Compresses sclera - Common way to treat detachment - Buckle may cover only the area behind the detachment or may encircle the eyeball like a ring - Vitrectomy - Intraocular procedure - Vitreous humor is removed to provide better access to the retina - Gas bubble, silicone oil, perfluorocarbon & liquids may be injected into vitreous cavity - Vitreous that's removed doesn't grow back - Must lie face down for about a week to help the retina heal **[Retinal Surgery -- Nursing Management]** - Patient education - Eye surgery is most often done as an outpatient procedure so patient education is vital - Signs & symptoms of complications, especially increased IOP & infection - Promote comfort - Patient may need to lie in a prone position for several days - May elicit reflux & may need a medication for comfort **[Macular Degeneration]** - Accounts for 54% of all blindness in older adults, loss of center of visual field - Macula is responsible for visual acuity in central field - Drusen in macula contributes to gradual blurry of vision (outside macula does not affect vision) - Types - Dry or nonexudative type; most common, 85-90% - Slow breakdown of the layers of the retina with the appearance of drusen (debris or waste under the retina) - Macula becomes thinner with age & drusen (lipids) accumulate in & around macula - Limited treatment: delayed with antioxidants, multivitamins, smoking cessation - Wet type - May have abrupt onset, more advanced - Proliferation of abnormal blood vessels growing under the retina leak fluid blood that contributes to fast, blurry vision loss - Treatment: meds that prevent growth of leaky blood vessels in eye - No known effective therapy for the dry type of AMD (atrophic macular degeneration) - Risk factors: family history, smoking, elevated cholesterol A diagram of the eyeball Description automatically generated with medium confidence  **[Ocular Consequences of Systemic Disease]** - Diabetic retinopathy - Damage to blood vessels that nourish retina - Diabetes is a leading cause of blindness in people aged 20 to 74 years - After 20 years with disease, almost everyone with type 1 & majority of those with type 2 have it - Painless process - Microaneurysms that leak fluid & deposits that form hard exudates progresses increases in destruction to vessels - Advanced stages grow new vessels that bleed vitreous & block light impaired vision & blindness - Ruptured vessels in retina form scar tissue that can pull on & detach retina - Manage blood glucose & stop smoking - Educate patients about prevention efforts - Laser can also help to destroy the leaky vessels & bad vessels - Eye changes associated with hypertension - Signs develop late in disease - Signs: arterial constriction, AV nicking, vascular wall changes, yellow hard exudates, hemorrhages, cotton wool spots, optic disc edema - Cotton wool spots indicate hypertension or diabetic retinopathy - Ophthalmic complications associated with advanced HIV/AIDS - Cytomegalovirus retinitis & cotton wool spots - Cytomegalovirus is a virus related to herpes & causes inflammation - Produces retinal necrosis & hemorrhage - Floaters, blurred vision, photophobia, blind spot, loss of peripheral vision - Antiretrovirals help (for patients without HIV/AIDS) **[Trauma]** - Prevention of injury - Patient & public education - Emergency treatment - Flush chemical injuries - Begin within 5 minutes of exposure & continuously flushed for 20 minutes with tap water - Save the bottle & bring to ER so provider has that info - Do not remove foreign objects - Protect using metal shield or paper cup - Potential for sympathetic ophthalmia causing blindness in the uninjured eye with some injuries - Sympathetic ophthalmia: an inflammatory condition created in the uninjured eye by the affected eye blindness in the uninjured eye; treated with corticosteroids & immunosuppressants, or enucleation in extreme cases - Enucleation: remove eyeball **[Safety Measures & Education]** - Prevention of eye injuries; education to prevent injuries - Safety strategies for patients with low vision in the hospital & home setting - Patient education after eye surgery or trauma - Potential complications - Loss of binocular vision with patch or vision impairment of one eye; safety - Use of eye patch & shield - Report any escalations in symptoms to provider **[Assessment of the Ear & Hearing]** - Ear assessment: - Inspection & palpation of external ear - Otoscopic examination - Hearing Assessment: - Gross auditory acuity - Whisper test - Weber test -- testing for lateralization (if patient hears stronger on one side) - Rinne test -- testing air conduction (normal is a positive test AC \> BC) **[Hearing Impairment]** - Presbycusis = age-related hearing loss; gradual; initially affects higher pitched sounds - Prevalence increases with age; 50% over the age of 70 - Risk factors include exposure to excessive noise levels - Types - Conductive: caused by external or middle ear problem - Sensorineural: caused by damage to the cochlea or vestibulocochlear nerve - Mixed: both conductive & sensorineural - Functional (psychogenic): caused by emotional problem **[Hearing Impairment Manifestations]** - Early symptoms - Tinnitus: perception of sound; often "ringing in the ears" - Increased inability to hear in a group - Turning up the volume on the TV - As hearing loss increases, person may experience deterioration of speech, fatigue, indifference, social isolation or withdrawal **[Ménière's Disease]** - Abnormal inner ear fluid balance caused by malabsorption of the endolymphatic sac or blockage of the endolymphatic duct - Manifestations: - Episodic vertigo, tinnitus, hearing loss. Feeling of fullness or pressure, nausea & vomiting may occur - Bilateral - Smoking, infection & high-salt diet worsens symptoms - Treatment - Low-sodium diet:1,000-1,500 mg/day; avoid caffeine, smoking cessation - Meds: Meclizine (Antivert); tranquilizers (Valium), antiemetics (Promethazine) & diuretics may be used - For motion sickness & nausea - Diuretics for ear fluid - Surgical management to eliminate attacks of vertigo; endolymphatic sac decompression, middle & inner ear perfusion & vestibular nerve sectioning **[Treatment for Hearing Impairment]** - Hearing Aids - Device to amplify sound & improve hearing - Cochlear implant - Auditory prosthesis used for people with profound sensorineural hearing loss bilaterally who do not benefit from conventional hearing aids - Vestibular rehabilitation (outpatient clinic) - A type of therapy focused on improving balance & stability for conditions affecting the inner ear **[Guidelines for Communicating with Hearing Impaired Person]** - Use a low-tone, normal voice - Speak slowly & distinctly - Reduce background noise & distractions - Face the person & get their attention - Speak into the less impaired ear - Use gestures & facial expressions - If necessary, write out information or obtain a sign language translator **Peri-Op** **[Perioperative Nursing]** - Preoperative phase: begins when the decision to proceed with surgical intervention is made & 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 & ends with admission to the PACU (post anesthesia care unit) - Postoperative phase: begins with the admission of the patient to the PACU & ends with a follow-up evaluation in the clinical setting or home **[Surgical Classification]** - Facilitating a diagnosis (laparotomy), a cure (appendicitis), or repair (wounds) - Reconstructive (mammoplasty), cosmetic (facelift), or palliative (tumor debulking) - Rehabilitative (joint replacement) - Based upon the degree of urgency involved: - Emergent (without delay) - Hemorrhage - Urgent (within 24-30 hours) - Appendectomy - Required (few weeks/months) - Cataract, joint replacement - Elective (failure to have surgery is not a catastrophe) - Scar repair - Optional (personal preference) - BBL **[Preoperative Care -- Preadmission Testing]** - Initiates the nursing process - Admission data: - Demographics, health history, other information pertinent to the surgical procedure - Verifies completion of preoperative diagnostic testing - Labs & diagnostic studies - Begins discharge planning by assessing patient's need for postoperative care **[Preoperative Assessment]** - Health history & physical exam - Medications & allergies - Previous & current medication use - Food, drug, latex, other allergies - Nutritional, fluid status - Optimize health - Dentition - Thrush or inflammation may indicate signs of infection & surgery might be delayed - Drug or alcohol use - Current or history - May impede meds - Respiratory & cardiovascular status - Breathing exercises - Hepatic, renal, endocrine & immune function - Psychosocial factors, spiritual, cultural beliefs - History of n/v with prior surgery - Prevent intraoperative n/v that can lead to aspiration - History of heat stroke or hyperthermia after exercise; muscle cramping with increased temp (lets us know if the patient is at increased risk for malignant hypothermia) - Family history of death accompanied by elevated temp (lets us know if the patient is at increased risk for malignant hypothermia) **[Medications that Potentially Affect Surgical Experience]** - Corticosteroids need to taper - Diuretics excessive respiratory depression - Phenothiazines hypotensive effects - Tranquilizers - Insulin - Antibiotics - Anticoagulants bleeding risk - Anticonvulsant medications - Thyroid hormone - Opioids - Over the counter & herbals - ASA, Gingko bleeding - Echinacea, Kava liver damage - Garlic supplements lower BP - Ginseng raise BP, rapid HR - Ephedra raise BP, abnormal heart rhythms - St. John's Wort harder to recover from effects of anesthesia - Valerian harder to wake after anesthesia, abnormal heart rhythms **[Gerontologic Considerations]** - Cardiac reserves are lower - Renal & hepatic functions are slower - Gastrointestinal activity is likely to be reduced - Respiratory& cardiac compromise are the leading causes of morbidity & mortality - Decreased subcutaneous fat, more susceptible to temperature changes - May need more time & multiple explanations to understand & retain what is communicated postoperatively **[Informed Consent]** - Should be in writing before non-emergent surgery - Legal mandate - **Surgeon must explain the procedure, benefits, risks, complications, etc.** - **Nurse clarifies information & witnesses' signature** - Consent is valid **ONLY** when signed before administering psychoactive premedication - Consent accompanies patient to OR **[Preoperative Nursing Interventions]** - Providing patient education - Deep breathing - Coughing - Incentive spirometry - Mobility & active body movement - Ambulate day 1 post op if no complications - Pain med schedule & encourage early mobilization - Education for patients undergoing ambulatory surgery - Come in morning & leave afternoon - Do not remain in care so need a lot of education - Cognitive coping strategies - Imagery, distraction, optimism, soft music - Psychosocial interventions - Reducing anxiety & fear - Respecting cultural & religious beliefs - Maintaining patient safety - Managing nutrition & fluids - Preparing bowel - Clear bowel before - Preparing skin - Antiseptic washes, clipping hair **[Immediate Preoperative Nursing Interventions]** - Patient changes into gown, 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 True or False: The primary goal in withholding food before surgery is to prevent aspiration - TRUE (minimum of 8 hours prior to surgery) The nurse is preparing to administer premedication. Which actions should the nurse take first? A. Have family present B. Ensure that the preoperative shave is completed C. **Have the patient void** a. **Prevent falls & injury because the med is probably sedative** D. Make sure the patient is covered with a warm blanket **[Intraoperative Care -- Members of the Surgical Team & Roles]** - Patient - Anesthesiologist (physician) or certified registered nurse anesthetist (CRNA) - Surgeon - Nurses - Circulating nurse - Asepsis maintained, timing, documenting, safety, timeout procedure (just before surgery), maintain temp of room, supply - Timeout: name patient, ID patient, state surgical procedure, confirm everything that is happening; final safety check (patient may even be awake for this) - Scrub role (LPN, RN, surgical technologist) - Hand hygiene, sets up field, anticipates supplies required - COUNTS to make sure nothing is left in patient - Registered nurse first assistant (RNFA) - Surgeons first assistant - They practice in 17 states - Note: role of nurse as patient advocate - Surgical technicians - Transport patients to OR, prepare room/equipment - Certified surgical technologists (assistants) - Assist surgeon **[Prevention of Infection]** - Surgical environment - Unrestricted zone: street clothes allowed - Semi-restricted zone: scrub clothes & caps - Restricted zone: scrub clothes, shoe covers, caps & masks - Surgical asepsis - Environmental controls - Meticulous cleaning & maintenance of OR equipment, sterilized equipment, linens, drapes & solutions - Surgical Care Improvement Project (SCIP) - National goal to reduce surgical site infections - Prophylactic antibiotics within hour of surgical start time & 24 hours end time - VTE prophylaxis (for emboli) **[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 - Movements of surgical team are from **sterile to sterile**, from **unsterile to unsterile** only - 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 - Items of doubtful sterility considered unsterile - Sterile fields prepared as close to time of use **[Intraoperative Complications]** - Anesthesia awareness - Unintended, patient becoming cognizant of surgical procedure - PTSD - Increased BP, HR, movement - Caused by inadequate anesthesia, equipment misuse - Nausea, vomiting - Turned to side, suction - Anaphylaxis - Hypoxia, respiratory complications - Hypothermia (unintentional) - Low temp of OR, low temp of fluids - Open body cavities - Malignant hyperthermia - Rare, inherited muscle disorder induced by anesthesia - STOP surgery & anesthesia, Dantrolene IV, oxygen, lower body temp, control HR a& BP, correct electrolyte imbalances (symptoms resolve within 48 hours if caught early) - Infection **[Adverse Effects of Surgery & Anesthesia]** - Allergic reactions, drug toxicity or reactions - Cardiac dysrhythmias - CNS changes - Mood swings, insomnia - Trauma: laryngeal, oral, nerve, skin, including burns - Difficult intubation may cause sore throat & bleeding - Skin: prolonged immobility, burns from certain equipment - Hypotension - Thrombosis **[Gerontologic Considerations]** - Higher risk for complications from anesthesia & surgery vs. younger adults due to: - Age-related cardiovascular & pulmonary changes - Decreased tissue elasticity - Lung & cardiovascular systems & reduced lean tissue mass - Decreases the rate at which the liver can inactivate many anesthetic agents - Decreased kidney function slows the elimination of waste products & anesthetic agents - Impaired ability to increase metabolic rate & impaired thermoregulatory mechanisms **[Protecting the Patient from Injury]** - Patient identification - Informed consent - Verification of records of health history, exam - Results of diagnostic tests - Allergies (include latex allergy, bracelet if allergy present) - Monitoring, modifying physical environment - Safety measures (grounding of equipment, restraints, not leaving a sedated patient) - Verification, accessibility of blood - Compatible blood **[Intraoperative Patient -- Nursing Interventions]** - Reducing anxiety - Reducing latex exposure - Preventing perioperative positioning injury - Protecting patient from injury - Serving as patient advocate - Monitoring, managing potential complications **[Nursing Management in the Post Anesthesia Care Unit (PACU)]** - Provide care for patient until patient has recovered from effects of anesthesia - Assess patient for vital signs - Assess orientation - Assess for resumption of motor & sensory function - No evidence of hemorrhage or complications from surgery - Frequent skilled assessments of patient **[Responsibilities of the PACU Nurse]** - Review pertinent information, baseline assessment upon admission to unit - Assess airway, respiratory function, cardiovascular function, skin color, LOC & ability to respond to commands - Some drowsiness is expected - Reassess VS, patient status every 15 minutes or more frequently as needed/ordered - Administration of postoperative analgesia - Transfer report, to another unit or discharge patient to home **[Outpatient Surgery/Direct Discharge]** - Discharge planning, discharge assessment - Provide written, verbal instructions regarding follow-up care, complications, wound care, activity, medications, diet - Give prescriptions, phone numbers - Discuss actions to take if complications occur - Give instructions to patient & responsible adult who will accompany patient - Educate about side effects & when to contact the provider - Patients are **not to drive home or be discharged to home alone** - Sedation, anesthesia may cloud memory, judgment, affect ability **[Nursing Management of the Hospitalized Postoperative Patient]** - Assessment - Vital signs - Pain - Mental status/LOC - General discomfort - Surgical site **[Maintaining a Patent Airway -- Post Op]** - Primary consideration: necessary to maintain ventilation, oxygenation - Provide supplemental oxygen as indicated - Assess respiratory status (RR, SpO~2~, auscultate lungs) - Keep head of bed elevated 15 to 30 degrees or higher unless contraindicated - May require suctioning - If vomiting occurs, turn patient to side - An oral airway may be used **[Maintaining Cardiovascular Stability]** - Monitor all indicators of cardiovascular status - Fluid status, ECG, HR, BP - Assess all IV lines - Patent IV access for emergency - Potential for hypotension, shock - Potential for hemorrhage - Potential for hypertension, dysrhythmias **[Indicators of Hypovolemic Shock/Hemorrhage]** - Pallor - Cool, moist skin - Rapid respirations - Cyanosis - Rapid, weak, thread pulse - Decreasing pulse pressure - Low blood pressure - Concentrated urine - Decreased perfusion to kidneys **[Managing Post Op Symptoms]** - Relieving Pain & Anxiety: - Assess patient comfort - Control of environment: quiet, low lights, noise level - Administer analgesics as indicated; usually short-acting opioids IV - Addressing family anxiety - Controlling Nausea & Vomiting - Administer antiemetics, as indicated - Assess effectiveness of medications **[Gerontologic Considerations]** - Decreased physiologic reserve - Peak around 25 & naturally declines - How the body response to stress - Effects of anesthesia are more critical in older adults (low & slow for older patients) - Monitor carefully, frequently - Hypoxia, hypotension, hypoglycemia - Hydration status - Pain management dosage ("go low & slow") - Increased likelihood of postoperative confusion, delirium - Reorient as needed **[Wound Healing]** - Factors that affect wound healing - Age, nutritional deficits, medications, comorbidities (diabetes), systemic disorders, wound stressors (straining, obesity, heavy coughing), etc. - Dehiscence: partial or total separation of wound layers because of excessive dress on wounds that are not healed - Evisceration: abdominal wall completely separates, with protrusion of viscera (internal organs) through the incisional area - Notify surgeon **IMMEDIATELY** - Do not want strain on surgical site: splint when coughing, deep breathing when they feel urge to cough, stool softeners, binders **[Types of Surgical Drains]** - Penrose: open tubing incised in wound to keep drain from slipping into wound; placed in anticipation of large amounts of drainage; no receptable for drainage - Drain sponge placed to measure drainage (soaked through 2 layers of gauze) - Jackson-Pratt: sutured in place with bulb syringe that compresses; suction is maintained to pull drainage; you can measure output with this blub as well - Hemovac: joint surgeries like total hip arthroplasty; compressed to suction; output can be measured **[Purpose of Postoperative Dressings]** - Provide healing environment - Absorb drainage - Sterile gauze or other absorbent dressing - Incision Management System (Prevena VAC) - Maintain integrity of incision (not drainage) - 2-7 days of use; no dressing changes needed - Negative pressure vacuums assisted closure dressing (Wound VAC) - For wound healing: sponges cut to fit wound; changed every 40-72 hours, more if infected but no more than 3 times/week; encourage granulation of tissue - Splint or immobilize - Protect surgical site - Promote homeostasis - Promote patient's physical and mental comfort **[Change the Postoperative Dressing]** - First dressing changed by surgeon/provider - Types of dressing materials - Sterile technique - Assess wound - Applying dressing, taping methods - Assess patient response - Tolerated well, fair, poor - Patient teaching - Documentation **[Potential Post-Op Complications]**  **[Patient Controlled Analgesia (PCA)]** - Allows self-administration of **pain medication** in immediate postoperative period - A syringe of pain medication, as prescribed by a provider, is placed on a special, programmable pump, and is connected directly to a patient\'s intravenous (IV) line - Pain medication can be delivered on demand or by slow continuous infusion - Criteria for PCA: - Understanding of the need to self-dose - Physical ability to self-dose - Goal: - Pain prevention, promote patient participation in care, eliminates delayed pain management, maintains a therapeutic level of pain medication thereby enabling a patient to move, turn, cough, deep breath, thus reducing post-op complications **[PCA Pump]** - Delivery - On demand (push the button) vs. Continuous infusion - Locked box - Medication administered on a pump in a clear, locked chamber - If ordered on demand, patient instructed to press button for a dose every few minutes & they will not be overdosed - PCA pump programmed per Rx to deliver a certain amount of medication within a certain timeframe - Ex: Dilaudid 0.2mg IV every 6 minutes via PCA, with a 4-hour max dose of 4 mg - All programmed in the PCA pump-medication, dose, frequency, and 4-hour dose limit - Entered in the system with another nurse as a witness - When removing, you also need to measure how much is left & measure with another nurse as a witness - Monitor patient on this: check respiratory rate **[PCA Nursing Management]** - Assess - Vital signs (especially respiratory rate RR and pulse oximetry (SpO~2~)) - Pain level and response to PCA - Level of consciousness - IV site - Attempts vs. delivered amount of medication - More attempts vs. Delivered Is the patient receiving adequate pain control? - Few attempts and delivery Is the PCA still necessary? - Before discontinuing the PCA, inquire about necessity of PO pain meds for longer term, consistent pain management - Complications - Respiratory distress - Sedation - Constipation - Family/support system interference - Family may **NOT** press the button for the patient if they perceive the patient is in pain - Document - Pain assessment (before & after dosing at initiation and every 2 hours or per facility protocol) - Vital signs (especially RR & pulse oximetry) - Readiness for discontinue PCA & transition to PO pain meds - When PCA is discontinued, how much (in mL) left in the syringe = amount of medication wasted with a witness - Controlled substances must be wasted with a RN witness when being discarded - Document name of RN witness of waste **Endocrine** **[Hormone Overview -- Hypothalamus]** - Base of skull - Links brain to endocrine system connected by a stalk containing nerves & blood vessels - This stalk is how hormones made from the hypothalamus travel to the pituitary  **[Hormone Overview -- Pituitary & Pineal Glands]** - Anterior Pituitary - ACTH (Adrenocorticotropic hormone) - Stress response, stimulates adrenal gland to produce cortisol - Regulates metabolism, BP, blood glucose, reduces inflammation - FSH (Follicle Stimulating Hormone) - Sperm production in AMAB & ovaries to produce estrogen & egg development in AFAB - GH (growth hormone) - Stimulates growth - Makes you taller as a child - Adults: maintains healthy muscle & bones, impacts fat distribution, metabolism - LH (luteinizing/gonadotropin hormone) - Stimulates ovulation & testosterone production - Function of ovaries & testes - PRL (prolactin) - Stimulates breast milk production after birth - Affects fertility & sexual function - TSH (thyroid stimulating hormone) - Stimulates thyroid hormones T3 & T4 to manage metabolism, energy levels, brain development, cell replication - Posterior Pituitary (storage and release) - ADH/vasopressin - Regulates water balance & sodium levels in body (serum osmolarity) - Ex: dehydration less water higher serum osmolarity - Oxytocin - Laboring process progress labor during childbirth by sending signals to uterus to contract - Parent & child bonding - Mobilizing sperm - Pineal - Melatonin - Sleep - Secretion is connected to time of day - Declines with age **[Positive Feedback Loop]** - Infant suckling activates nerves leading to hypothalamus tells hypothalamus to make oxytocin pituitary releases oxytocin oxytocin acts on breast tissue to allow milk to flow **[Negative Feedback Loop]** - Increased levels of cortisol in the blood trigger stop cortical releasing hormone by hypothalamus stop ACTH from being released from pituitary gland (acts on adrenal glands that release cortisol)  - Increase in growth hormone triggers hypothalamus (makes and releases growth hormone) acts on pituitary gland that releases growth hormone to stop releasing growth hormone  **[Hormones -- Ovaries & Testes]** - Ovaries - Estrogen - Peak before ovulation, increase during luteal phase - Progesterone - Peak post ovulation - Fluctuates across a 28-day cycle - Testes - Estradiol - Testosterone **[Hormones -- Adrenal Gland]** - Cortex: Steroid hormones - Glucocorticoids (cortisol) - Glucose metabolism; impacts glucose, protein, fat metabolism, stress, immune function - Increased cortisol secretion increased blood glucose levels - Inhibit inflammatory process - Prevent tissue rejection - Side effects: diabetes, osteoporosis, peptic ulcer, redistribution of body fat, poor wound healing, muscle wasting - Mineralocorticoids (aldosterone) - Act on renal tubules & GI epithelium to increase sodium reabsorption & excrete K+ & H+ - Aldosterone is main hormone for long term regulation of sodium balance - Sex hormones (androgens & estrogen) - Androgens associated with start of puberty & reproductive health & body development (i.e. testosterone) - Testes & ovaries produce them mostly, but so do adrenal glands - Medulla: Catecholamines - Epinephrine - 90% of secretion - Fight or flight response - Norepinephrine **[Thyroid Hormone]** - Comprised of T3 & T4, calcitonin (secreted in response to high plasma levels of calcium & reduces the plasma level of calcium by increasing its deposition in bone) - Iodine is essential to create hormones - Get iodine from diet - Secretion of T3 & T4 is controlled by TSH - Thyroid hormones impact cell replication, which is important for brain development, normal growth, bone health, digestion, metabolism - Effects every major organ system & tissue function (basal metabolic rate, metabolism, cholesterol levels, vascular resistance) - Low levels of iodine triggers elevated TSH, overproduction of T3 & T4, hypertrophy of thyroid gland goiter - Iodized salts help to eliminate goiters - Euthyroid = normal functioning thyroid **[Parathyroid Glands]** - Secrete parathyroid hormone regulate calcium & phosphorus metabolism - Tends to lower blood phosphorus level - Increased secretion of PH increased calcium absorption from kidney, intestines, bones raise serum calcium level increased calcium results in decreased PH secretion - Negative feedback! - Hyper parathyroid results from overproduction of parathyroid mode & causes bone decalcification & the development of renal calculi or kidney stones containing calcium - Symptoms: pain, fatigue, muscle weakness, nausea, vomiting, constipation, hypertension, cardiac arrythmias may occur, anorexia - Treatment: removing 1 or more glands, minimally invasive, outpatient - Require increase in daily fluid intake (more than 2 liters) to prevent renal calculi formation - Walking is encouraged because bones that experience stress from walking release less calcium - Bedrest also increases calcium excretion & other risk of kidney stones - Encourage appetite and PO intake - Eat normal levels of calcium - For constipation: prune juice, activity, stool softener - Hypo parathyroid caused by removal of thyroid glands - When there is a toxic thyroid that needs to be removed, parathyroid may be partially removed or damaged - Other causes: autoimmune response, vitamin D deficiency - Causes hyperphosphatemia (increased blood phosphate levels) & hypocalcemia (low calcium) - Hypocalcemia is chief symptoms of hypoparathyroidism which is tetany muscle tremors & spasms in the arms & legs with later signs being numbness & tingling in hands & feet, positive spastic & trousseau signs - Goal of therapy is to increase serum calcium up to 9/10 (normal is 8.5-10.5) - Treatment: calcium, magnesium, herbal calciferol, calcitriol (preferred) **[Pituitary Disorders]** - Acromegaly - Diabetes Insipidus - SIADH **[Acromegaly]** - Rare disorder of GH in adults - Increase in GH, increase in size of body parts, no height increase - Often caused by a pituitary tumor - Labs, x-rays, CAT scans to diagnose - Coarse facial features - Enlarged forehead, lips, ears, lower jaw protrusion - Wide spaces between teeth, enlarged tongue - Soft tissue swelling - Enlarged hands and feet, thickened skin - Deepening of voice, oily skin, excessive sweating, carpal tunnel, sleep apnea, osteoarthritis, severe headaches, sweating, hypertension - Onset is gradual over years - Left untreated hypertension, diabetes mellitus, heart problems - Treatment depends on cause (Ex: tumor) - Surgery, meds, radiation therapy - Surgery: removing pituitary adenoma (trans nasal approach) - Meds: inhibit release of growth hormones - Radiation is used when surgery or meds are not sufficient - Rx: - Inhibit GH release: octreotide (sandostatin), lanreotide (somatuline) - Significant shrinkage of tumor in 30-50% patients - GH receptor blocker: pegvisomant (somavert) - Psychosocial support, medication education **[Diabetes Insipidus]** - Deficient ADH - Rare, injury caused to hypothalamus or pituitary glands that results in deficiency of ADH (secreted by posterior pituitary) - Decreased ADH reduces ability of distal renal tubules & kidneys to collect & concentrate urine excretion of large volumes of dilate urine, excessive thirst, excessive fluid intake, electrolyte imbalances - Causes: central & nephrogenic - Central: from brain, head trauma, surgery, infection, inflammation, brain tumors, radiation in or around pituitary gland - Nephrogenic: originates in kidneys where renal tubules do not react to ADH; cause is adverse effect from meds like lithium or tetracycline antibiotics or the result of kidney injury/electrolyte imbalances (hyperkalemia or hypercalcemia) - Symptoms: dehydration, dry and cracked lips, confusion, weakness - Assessment: - Polyuria: 3-20 L/day and consequent polydipsia - Tachycardia, hypotension, loss or absence of skin turgor, dry mucus membranes, weak pulses, decreased cognition, constipation, nocturia, fatigue, weight loss, dilute urine - Labs: - Urine: low specific gravity \< 1.005; low osmolality \< 200mOsm/L; low urine pH, Na & K - Super dilute - Blood: high blood osmolality \> 300 mOsm/L; high Na & K - Very concentrated and high osmolarity in blood - Care: - Vital signs, urinary output, I/Os, specific gravity, labs (K, Na, BUN, Cr, spec gravity, osmolarity), daily weights, IV hydration, electrolyte replacement PRN, fall precautions, skin turgor, mucous membranes, high fiber, diet avoid alcohol consumption/caffeine - Complications: - Dehydration, hypernatremia, unconsciousness, CNS damage, seizures, circulatory collapse **[Syndrome of Inappropriate Antidiuretic Hormone (SIADH)]** - Excess ADH, excess fluid retention - Causes: - Tumors, head injury, meningitis, medications (anesthetics, chemotherapy agents, antidepressants (SSRIs, TCAs), opioids, barbiturates) - Assessment: - Early: headache, weakness, anorexia, muscle cramps, water weight gain, s/s fluid volume excess (crackles, distended neck veins, HTN) - Late: confusion, lethargy, nausea, vomiting, diarrhea, oliguria, Cheyne-Stokes respirations, seizures - Oliguria = dark, concentrated urine (less output) - Care: I/Os and restricting fluid intake, daily weight, urine and blood chemistries & neurologic status, administer diuretics & hypertonic NaCl (3%) for severe hyponatremia may be Rx - Treat underlying cause and symptom management - Complications: water intoxication, severe hyponatremia coma death - Water intoxication: crackles in lungs, distended neck veins, confusion, headache, disorientation, muscle cramping - Hyponatremia can lead to cerebral edema, pulmonary edema, coma and death - Dilutional hyponatremia: retaining so much water that these patients are essentially hyponatremic **[Hypothyroidism ]** - Decreased levels of thyroid hormone think SLOW - Impacts metabolism so everything will slow down - Causes: - Autoimmune thyroiditis (Hashimoto disease), hyperthyroid treatment (radioactive iodine or antithyroid meds), thyroidectomy - Myxedema is severe form of hypothyroidism - Hashimoto\'s is most common - Assessment: - Fatigue, lethargy, sleep a lot, constipation, cold intolerance, thinning hair/eyebrows, weight gain, swelling of face, hands, feet, enlarged tongue, slow speech/thoughts, bradycardia, deeper voice, etc. - Menorrhagia in menstruating adults - In myxedema: hypothermia, personality & cognitive changes (like dementia), sleep apnea, pleural effusion, pericardial effusion, respiratory muscle weakness; sensitive to sedatives, opioids, anesthetics - Coma: hypothyroid, hypothermic, unconscious - Develops with undiagnosed hypothyroidism or follows infection/sedatives/opioid analgesics - Hyponatremia, hypoglycemia, hyperventilation, hypotension, bradycardia, hypothermia - Contribute to cardiovascular shock & collapse & require critical care - Care: - Levothyroxine 75 -- 150 mcg PO daily on empty stomach with full glass of water - Older adults require a lower dose - Start low & titrate until desired TSH - For older adults - Prevalence increases with age & signs of hypothyroidism can be confused with signs of aging - Supportive care - Complications: - Myxedema (severe deficiency), Myxedema coma (rare, life-threatening condition) **[Hyperthyroidism]** - Increase in levels of thyroid hormone think FAST - From excessive endogenous thyroid hormone or exogenous (from meds) - Causes: - Graves' disease (autoimmune), thyroiditis (inflammation), excessive intake of thyroid hormone - Graves is most common cause - Assessment: - Anxious, restless, irritable, muscle weakness and wasting, tremors, emotional lability, decreased attention, sinus tachycardia or arrhythmias, insomnia, diarrhea, weight loss, warm/sweaty/flushed skin, perspiration, big appetite, heat intolerance, fine hair, exophthalmos, goiter, etc. - Oligomenorrhea: irregular & inconsistent period - If left untreated & severe enlargement of heart (myocardial hypertrophy) & eventual heart failure - Graves' disease will present with exophthalmos, goiter, pretibial myxedema - Exophthalmos: occurs from edema in extra ocular muscles & increased fatty tissue deposits behind eye - Blurry vision, double vision, tiring of eyes - May not be reversible even with treatment - Pretibial myxedema: dry, waxy, swelling of front surfaces of lower legs that resemble benign tumors - Treatment: antithyroid meds, radioactive iodine, beta blockers for symptom management (cardiac), thyroidectomy - Radioactive iodine is effective in 80-90% of patients (1 dose) - Care - Antithyroid meds, radioactive iodine (^131^I), beta blockers, surgery - Complications: - Thyroid storm (\> 101.3°F, \> 130 bpm, altered neuro state, & exaggerated hyperthyroid symptoms), hypocalcemia/tetany, nerve damage (vocal disturbances/vocal cord paralysis) - Thyroid storm: life threatening condition of thyroid due to untreated hypothyroidism; triggered by stress (injury/infection/surgery/pregnancy/withdrawal from meds/emotions) - Abrupt onset, almost always fatal without prompt treatment - High fevers, tachycardia, exaggerated symptoms of hyperthyroidism, change in LOC, psychosis, coma - Treatment: temperature & cardiac - Temp: hypothermic blankets with ice packs, acetaminophen, humidified oxygen, IV fluids, dextrose, propylthiouracil or Methimazole to block conversion of T3 & T4, hydrocortisone for shock or adrenal insufficiency, iodine - Cardiac: propranolol, digoxin - NO ASPIRIN, SALICYLATE, SULFATES - They displace thyroid hormone from binding proteins & worsen hypermetabolism  **[Adrenocortical Insufficiency (Addison's Disease)]** - Damage or dysfunction of adrenal cortex decrease steroids in adrenal glands - Decreased aldosterone & cortisol - Causes: - Autoimmune, surgery, cancers, steroid withdrawal - Meds that can cause this: rifampin, barbiturates, ketoconazole, tyrosine kinase inhibitors, sudden stopping of exogenous steroid therapy - Adrenal insufficiency should be considered in any patient who has been treated with corticosteroids - Loss of mineralocorticoid increased secretion of NaCl, increased retention of K, hypoglycemia, weakness, fatigue - Assessment: - Weakness/fatigue, weight loss, salt craving, hyperpigmentation (knuckles, knees, skin folds, mucus membranes), anorexia, n/v, hyponatremia, hypovolemia, hypoglycemia, hyperkalemia, hypercalcemia - Care: - Glucocorticoid replacement: hydrocortisone, prednisone, or cortisone - Mineralocorticoid replacement: fludrocortisone - Hydrocortisone IV, 0.9% NS/D5W IV fluids, vasopressors, antibiotics PRN, monitor/treat hyperkalemia & hypoglycemia - Complications: - Addisonian crisis (confusion & restlessness, severe hypotension, cyanosis, fever, n/v, signs of shock) - Acute adrenal insufficiency, abrupt onset, medical emergency - If not treated promptly, prognosis is poor - Signs of shock: hypotension, tachycardia that leads to arrythmias, LOC, being unresponsive, pallor, decreased urinary output, rapid and weak pulse, tachypnea - Treatment: lifelong oral replacement of adrenal cortex hormones (hydrocortisone, prednisone, cortisone) - Education! Monitoring! Safety precautions! - Severe cases: prevent and treat circulatory shock that could ensure (restore blood circulation, administer fluids and steroids IV, monitor vitals, lie flat, vasopressors) - Susceptible to infection to antibiotics - Monitor labs for hyperkalemia, hypoglycemia **[Cushing's Syndrome/Disease]** - Increase in adrenal cortex hormones - Causes: - Medications, hyperplasia of cortex, pituitary tumor - Can happen more in pts with history of asthma or arthritis from meds - Assessment: - Classic signs: central obesity, fat around the face (moon face), back of neck (buffalo hump) & abdomen - Weakness, fatigue, sleep disturbances, thin, fragile skin, striae, hypertension, hyperglycemia, heart failure, hirsutism, amenorrhea, depression, dark facial hair, poor wound healing, muscle wasting, osteoporosis, red cheeks - Risk for falls and fractures - Retain sodium & water as result of increased mineralocorticoid leading to hypertension & heart failure - Increase in androgen secretion in AFAB causes excessive facial hair, breast atrophy, cessation of menses - Treatment: - If med is cause: taper med to minimum dose needed to treat underlying disease - Hypertrophy: adrenalectomy to remove adrenal gland Pituitary tumor: surgery to remove tumor or pituitary gland (radiation is possible as well) - Care: - Depends on the cause: surgery or medication dosage adjustment; psychological support; maintaining adequate, cardiac function, decreasing the risk of injury & infection, promoting skin integrity **[Diabetes Mellitus (DM)]** - Chronic metabolic disorder characterized by hyperglycemia from inadequate production of insulin (Type 1), or cells do not respond to insulin (Type 2) - Types: - Prediabetes -- blood sugar \> normal, not high enough for type 2 diagnosis, aka impaired glucose tolerance or impaired fasting glucose) - 1/3 adults have it - Increase risk of type 2 diabetes, heart disease, stroke - Prevented with lifestyle - Type 1 -- inadequate production of insulin (fka insulin-dependent or juvenile diabetes) - Type 2 -- insulin resistance (fka non-insulin-dependent, adult-onset) - 95% have this - Gestational -- develops in pregnant people with no history of DM - Onset in 2nd or 3rd trimester - Can lead to macrosomia: babies in higher weight - Managed with diet modification, exercise & blood glucose monitoring - If hyperglycemia persists, then insulin is prescribed - Normal: eat insulin secretion increases moves glucose from blood & into muscle, liver, fat cells - Insulin transports & metabolizes glucose, tells liver to stop release of glucose, stimulates storage of glucose in liver and muscle in form of glycogen, enhances storage of dietary fat & adipose tissue, accelerates transport of amino acids from protein, inhibits breakdown of stored glucose, protein & fat - Type 1: beta cells of pancreas are destroyed so that there is decreased insulin production, increased glucose production by liver hypoglycemia - Glucose from food cannot be stored in liver, but will remain in bloodstream & contribute to postprandial hypoglycemia - Excess glucose is not reabsorbed by kidneys so passes in urine loss of fluid & electrolytes osmotic diuresis - Fat breakdown & production of highly acidic ketone bodies ketoacidosis (hyperglycemia, ketosis, metabolic acidosis) - Type 2 diabetes: impaired insulin secretion and insulin resistance - Insulin is less effective at glucose uptake by tissues & regulating the release of glucose by the liver - Increased amounts of insulin must be secreted to maintain blood glucose at normal level - Uncontrolled HHS (hypoglycemic hyperosmolar syndrome) - Signs and symptoms - Polyuria -- increased urination - Polydipsia -- increased thirst - Polyphagia -- increased appetite - Other: fatigue, sudden vision changes, dry skin, slow healing wounds, recurrent infections - Consequences of DM - Neuropathy -- numbness and tingling in hands or feet - Nephropathy -- kidney disease - Retinopathy - Treatment - Education - Medication - Diet & nutrition - Physical activity **[Diabetes Treatment -- Education]** - Pathophysiology - Basic definition of diabetes (having a high blood glucose level) - Normal blood glucose ranges & target blood glucose levels - Effect of insulin & exercise (decrease glucose) - Effect of food & stress, including illness & infections (increase glucose) - Basic treatment approaches - Treatment modalities - Administration of insulin & oral antidiabetic medications - Meal planning (food groups, timing of meals) - Monitoring of blood glucose and urine ketones - Recognition, treatment & prevention of acute complications - Hypoglycemia - Hyperglycemia - Pragmatic information - Where to buy & store insulin, syringes & glucose monitoring supplies - When & how to contact the primary provider **[Diabetes Treatment -- Medications]** - Oral Medications - Start at low dose & increase every 2 weeks until maximum dose is reached - Insulin injection - Mostly in type 1 - U-100 syringes - Note type of insulin Rx - Note onset, peak, duration of dose - Insulin pens - Prefilled cartridges of 150-300 units of insulin, disposable needles, good for travel or patients with problems with vision/dexterity - TEACH: must use insulin U-100 syringe for administration - Insulin pump - Continuous infusion of insulin, can give in a bolus as well - Change every 2-3 days to prevent infection - Complications: - Accidental cessation of insulin administration (turned off before a surgery & never turned back on) - Obstruction of tubing/needle - Pump failure - Infection A screenshot of a medical chart Description automatically generated **[Insulin Types & Sliding Scale]** - Rapid -- give when food is about to be eaten in 10 minutes, subcutaneous - Regular/short acting -- give 30 minutes before food, subcutaneous/IV - NPH -- 30-60 minutes before meals & at night for glycemic control throughout day - Long acting -- peak less, lasts 24 hours, subcutaneous ONLY - Sliding scale is based on glucose reading **[Diabetes Treatment -- Diet & Nutrition]** - Plate method - ½ plate is veggies, ¼ is proteins, ¼ is carbs - Talk to dietician, consider cultural preferences **[Diabetes Treatment -- Physical Activity]** - ADA Recommendations: - 150+ min/wk of moderate - to vigorous-intensity aerobic activity - 75 min/wk of vigorous-intensity or interval training - T1 & T2D should engage in 2--3 sessions/wk of resistance exercise on nonconsecutive days - Decrease sedentary behavior - Prolonged sitting should be interrupted every 30 minutes - Flexibility and balance training recommended 2--3 times/week. - Yoga & tai chi may be included based on individual preferences to increase flexibility, muscular strength, and balance. - Check blood glucose before & after physical activity **[Acute Complications of Diabetes]** - Hypoglycemia - Diabetic ketoacidosis (DKA) - Hyperglycemia hyperosmolar syndrome (HHS) **[Hypoglycemia ]** - Low blood sugar \ 600 mg/dL - Insulin is low, but not low enough that fat breakdown occurs (no ketone GI symptoms) - Increased osmolality \> 320 mOsm - Normal serum osmolality: 275-290 mOsm - Patients will report days-weeks of polyuria with adequate fluid intake - Neurologic changes, polyuria, hypotension, dehydration, tachycardia, seizures, hemiparesis, high glucose levels & osmolality, hallucinations, orthostatic hypotension - BUN & creatinine levels are elevated - Cerebral dehydration from extreme hyperosmolarity causes mental status changes, neuro deficits, hallucinations - Treatment (like DKA): fluid replacement, correct electrolyte imbalances & insulin administration - Close monitoring of volume and electrolytes to prevent fluid overload, heart failure, cardiac arrhythmias (older patients) - May take 3-5 days for neurologic symptoms to clear (are reversible) **Symptom** **DKA** **HHS** ----------------------------------------------- ------------------------------------------------- ------------------------------------------------- Polyuria  Checkmark with solid fill Polydipsia  Checkmark with solid fill Polyphagia  Checkmark with solid fill Weight loss  Checkmark with solid fill GI effects (nausea, vomiting, abdominal pain)  Blurred vision, headache, weakness Checkmark with solid fill  Orthostatic hypotension Checkmark with solid fill  Fruity odor of breath Checkmark with solid fill Kussmaul breathing  Metabolic acidosis Checkmark with solid fill Mental status changes  Checkmark with solid fill Seizures  Reversible paralysis Checkmark with solid fill **[Long Term Complications of Diabetes]** - Many people with metabolic syndrome have diabetes, cardiovascular disease, obesity, hyperlipidemia, hypertension, hyperglycemia - Macrovascular complications (vessel walls thicken & sclerosis & blood flow is blocked) - Coronary artery disease - Diminished peripheral pulses & intermittent claudication (pain in thigh, calf & butt when walking) - Can lead to gangrene & amputations - CAD in diabetes is 2-3 times likely to have a heart attack & death - Cerebrovascular disease - Atherosclerotic can lead to TIA or stroke & increased death from stroke - Peripheral vascular disease - Lower extremities - Microvascular complications: capillary wall thickening (impact smaller vessels in retina, kidneys) - Retinopathy - Damage to small vessels that feed the retina, causing visual impairments - Leading cause of blindness 20-74 years in USA - In type 1 & 2 diabetes - Can also lead to micro aneurysms, intracranial hemorrhage, hard exudates & capillary collapse leading to closure of vessels (decrease perfusion and visual acuity, blindness, cataracts, glaucoma) - Nephropathy - Diabetes patients account for almost half of new stages of end stage kidney disease - Ability of kidneys to filter has been stressed so proteins (albumin) leak into urine pressure in kidneys increase nephropathy - As kidney failure progresses, breakdown of exogenous and endogenous insulin hypoglycemia - Diabetic neuropathy - Peripheral neuropathy - Affects distal portions of nerves, moves proximal - Paresthesia: prickling, tingling, heightened sensations, burning in feet/hands/fingers - Decreased feeling in feet risk for falls & undetected foot infections - Foot & leg problems - Poor wound healing - Hyperglycemia risk of infection (impairs ability of leukocytes to destroy bacteria) - Injury to foot undetected can progress to osteomyelitis where the infection spreads to the bone & needs to be amputated - Amputations - Joint deformities (Charcot foot) - Result of neuropathy - Broken foot (warmth, redness, swelling); unilateral; may not report pain - Bones have fractured & collapsed onto each other - Nonsurgical & surgical approaches to fix - **Feet need to be examined daily** **[Foot Care]** - Take care of diabetes first (diet, nutrition, activity, insulin) - Inspect feet everyday - Wash feet every day in warm water **(NO SOAKING)** - Keep skin soft & smooth - Lotion on top and bottom of feet, but not between toes - Smooth corns & calluses **(NO SHAVING)** - Trim toenails each week straight across - Shoes & socks always **(NEVER BAREFOOT)** - Break shoes in slowly to avoid blisters - Protect from hot & cold temps - Keep blood flowing to the feet - Do not cross legs for long periods of time - No smoking (vasoconstriction) **Heme** **[Composition of Blood]** - Ratio of RBC to plasma - Males 40-54% - Females 37-47% - Hgb is O~2~ carrying capacity of blood - Male Hgb: 13-18 g/dL - Female Hgb: 12-15 g/dL - RBC (actual \# RBC in 100mL blood): - Male RBCs: 4.6-6.2 million/mm^3^ - Female RBCs: 4.2-5.4 million/mm^3^ **[Blood Transfusion]** - Done for RBCs, platelets, plasma - Verification - Order, Type and Screen, Consent, Education, Assess (v/s, lungs) - Type and screen: lab determines blood type & screening makes sure blood is a match to avoid transfusion reaction (rare, but harmful to kidneys & lungs & potentially life threatening) - RBCs contain antigens or protein markers that correspond to blood type so if wrong recipients' immune system will detect different proteins and destroy them - Nurse needs to witness consent signature - Educate on when to get nurse attention for potential transfusion reaction (back pain, trouble breathing, high temperature, etc.) - Rights of medication administration (medication, patient, dose, route, time, reason, documentation) - **Blood must be infused within 4 hours to avoid infection** - Do **NOT** exceed 5mL/min in first 15 minutes - Transfusion reactions - Febrile non-hemolytic reactions - Acute hemolytic reactions - Allergic reactions - Transfusion-associated circulatory overload (TACO) - Transfusion-related acute lung injury (TRALI) - Bacterial contamination - Signs/symptoms of transfusion reaction - Shortness of breath, back pain, dark urine, fever/chills, fainting or dizziness, flank pain, skin flushing, itching - **MUST stay with patient in the first 15 minutes to monitor for signs/symptoms** **[Transfusion Reactions]** - Febrile Non-hemolytic Reaction - Most common type of transfusion reaction, not life-threatening - Caused by antibodies to donor leukocytes that remain in the unit of blood or blood component - May be diminished or prevented by depleting the blood component of donor leukocytes or WBCs - Using leukocyte reduction filter - More common in patients who have had past transfusion & have been exposed to multiple antigens from those previous blood products - Signs/Symptoms: - Chills: (minimal to severe) followed by fever (more than 1°C elevation) - Fever: within 2 hours after the transfusion has begun - Fever, chills and muscle stiffness can be frightening to the patient (anxiety) - Acute Hemolytic Reaction - **[Most dangerous]**, and potentially life-threatening - Occurs when donor blood is incompatible with recipient - Reaction can occur after transfusion of as little as 10 mL of PRBCs - Signs/Symptoms: - Fever, chills, low back pain, nausea, chest tightness, dyspnea, anxiety, hematuria, hypotension, bronchospasm, & vascular collapse may result - Most common causes of acute hemolytic reaction are **errors in blood component labeling & patient identification** - Rights & scan barcode for safety measures - Attention to detail in labeling blood samples & blood components - Bar coding of blood products is an additional safety measure that has been implemented to ensure the safe transfusion of the right blood product to the patient - Allergic Reaction - Cause is thought to be a sensitivity reaction to a plasma protein within the blood component being transfused - Signs/Symptoms: urticaria (hives), pruritis (itching) & flushing - Rarely, the allergic reaction is severe, with bronchospasm, laryngeal edema & shock - Treated with epinephrine, corticosteroids & vasopressor support, if necessary - Transfusion-Associated Circulatory Overload (TACO) - Hypervolemia can occur if too much blood is infused too quickly; can be aggravated if patient already has increased circulatory volume (HF patients, renal function, older, acute MI at risk) - If rate is sufficiently slow, circulatory overload may be prevented - Packed RBCs are safer to use than whole blood - Remove excess components & infuse just what is needed (just give packed RBCs) - Signs/Symptoms: - Dyspnea, orthopnea, tachycardia, an increase in BP & sudden anxiety - Jugular vein distention, crackles at the base of the lungs & hypoxemia will also develop - Pulmonary edema can quickly develop, as manifested by severe dyspnea and coughing of pink, frothy sputum - Can develop as late as 6 hours after transfusion, monitor patient post transfusion (vital signs, breath sounds, JVD/fluid status) - Stop the transfusion; notify the provider; diuretics, oxygen, morphine to treat dyspnea - Transfusion-Related Acute Lung Injury (TRALI) - Fatal, idiosyncratic reaction of pulmonary edema in absence of circulatory overload - **Most common cause of transfusion-related death**, more likely with plasma & platelets - Development of acute lung injury within 6 hours post blood transfusion - Underlying pathophysiologic mechanism for TRALI is unknown - Signs/Symptoms: - Acute shortness of breath, hypoxia, hypotension, fever & eventual pulmonary edema - Stop transfusion and notify provider - Aggressive supportive therapy (e.g., oxygen, intubation, fluid support) may prevent death - Bacterial Contamination - Very low incidence - Can occur at any point during procurement or processing, often results from organisms on the donor's skin - Poor hand hygiene when blood is obtained or not efficient asepsis of skin when obtaining the blood - Can occur beyond 4-hour mark - Platelets at greater risk of contamination because stored at room temperature - Prevention: meticulous care in procurement & processing; must transfuse within 4 hours - Signs/Symptoms: - Fever, chills, and hypotension - Manifestations occur post transfusion, occasionally several hours post transfusion - Treat with IV fluids, broad-spectrum antibiotics - Sepsis IV fluids & antibiotics; corticosteroids & vasopressors (if severe) **[Transfusion Reactions -- Nursing Management]** - **Stop the transfusion. Maintain the IV line with normal saline** solution through new IV tubing, given at a slow rate, monitor vital signs, blood/urine samples as per hospital protocol - Assess the patient carefully - Vital signs including O~2~ saturation now vs. baseline - Respiratory status-adventitious breath sounds, accessory muscles, dyspnea - Change in mental status, anxiety, confusion - Chills, fever, diaphoresis - Jugular vein distention - Back pain (hemolytic reaction) - Urticaria - Notify the primary provider of the assessment findings & implement any treatments prescribed - Monitor the patient's vital signs & respiratory, cardiovascular & renal status - Notify the blood bank that a suspected transfusion reaction has occurred - Send the blood container & tubing to the blood bank for repeat typing and culture. The patient's identity & blood component identifying tags & numbers are verified **[Blood Types]** - Positive = have Rh protein - Negative = do not have Rh protein - Antigens are proteins on surface of blood cells that determine blood type; genetically determined - A = antigen A, B = antigen B, AB = antigens A & B - O = no antigens - Antibodies are specialized immune proteins produced based on antigens NOT present - Ex: have A antigens, then will develop B antibodies - Type B blood has anti-A antibodies in plasma - AB has neither AB antibodies in plasma which is what makes AB the universal recipient - O has both A & B antibodies present in plasma universal donor - Rh positive can receive more types of blood (+ and --) - Rh negative can only receive from other negatives - Negatives can donate to more types A patient with A^-^ blood type and a history of colorectal cancer is found to be anemic with a hemoglobin & hematocrit of 7.5 and 22. The patient's provider has ordered a transfusion of one unit of packed RBCs to be transfused over 3-4 hours. Describe the process for transfusion. Indicate the blood groups from which this patient may receive donor blood & the infusion rate of the packed RBCs to ensure transfusion within the ordered timeframe. - Verify the order, patient identity, patient consent, type & screen, educate the patient on signs/symptoms - Perform baseline assessment - Ensure proper IV access - Blood product verification (2-person check) - Compatible donors: A^-^ & O^-^ - Administration (Do **NOT** exceed 5mL/min in first 15 minutes) - **MUST** stay with patient in the first 15 minutes to monitor for signs/symptoms - One unit of PRBCs is \~300mL - To infuse over 3-4 hours, the infusion rate should be between 75-100mL/hour to finish in time - Post-transfusion, flush the line with saline & reassess the patient - Follow up labs to check H&H levels to assess the efficacy of the transfusion **[Hematologic Disorders]** - Blood - Anemias (hemolytic, hypoproliferative) - Sickle cell disease - Neutropenia - Polycythemia vera - Bleeding - Thrombocytopenia - Hemophilia - Platelet defects - Coagulation - Disseminated Intravascular Coagulation (DIC) **[Anemias]** - Lower than normal hemoglobin & fewer than normal circulating erythrocytes; a sign of an underlying disorder - Most common blood disorder - Hypoproliferative: defect in production of RBCs - Caused by iron, vitamin B12, or folate deficiency, decreased erythropoietin production, cancer - Hemolytic: excess destruction of RBCs - Caused by altered erythropoiesis, or other causes such as hypersplenism, drug-induced or autoimmune processes, mechanical heart valves - May also be caused by blood loss (GI bleed, stabbing, etc.) **[Hypoproliferative vs. Hemolytic Anemias]** - Hypoproliferative Anemias - Iron deficiency anemia - Anemia in renal disease - Anemia of inflammation - Aplastic anemia - Rare disease caused by decrease or damage to marrow stem cells - Megaloblastic anemia - Bone marrow produces unusually large, abnormal, immature RBCs called megaloblasts - From folic acid deficiency or vitamin B~12~ deficiency - Folic acid from diet - Vitamin B~12~ from diet or intrinsic factor - Glycoprotein produced by parietal cells of stomach (bariatric surgery removing parts of stomach, removing intrinsic factors B~12~ deficiency) - Malabsorption from Crohn's as well - Pernicious anemia from weakened stomach lining or autoimmune condition; present with fatigue, weakness - Patients with B~12~ anemia will have smooth, sore, red, beefy tongue and mild diarrhea, extremely pale, confusion, paresthesia, untreated nerve damage & damage to spinal cord - Hemolytic anemias - Sickle cell disease - Thalassemia - Inherited blood disorder where body makes abnormal or inadequate hemoglobin - Mostly in people from Mediterranean, North Africa, Middle East, India, Central Asia, Southeast Asia - Glucose-6-phosphate dehydrogenase deficiency - Immune hemolytic anemia - Hereditary hemochromatosis **[Anemia -- Assessment]** - Health history and physical exam - Religious restrictions (Ex: Jehovah's witness) - Presence of symptoms & impact of those symptoms on patient's life; fatigue, pallor (skin, mucous membranes), weakness/malaise, pain - Nutritional assessment - Result of diet? - Medications - Cardiac, GI, Neuro assessments - Blood loss - Menses, GI bleed, GYN bleed, internal bleed/large volume hemorrhage - Lab data: - **Hemoglobin & hematocrit** - **RBC indices** - **Iron studies** - Reticulocyte count - Vitamin B~12~ - Folate - Haptoglobin & erythropoietin levels - Bone marrow aspiration **[Anemia -- Medical Management]** - Correct or control the cause - Transfusion of packed RBCs - Treatment specific to the type of anemia - Dietary therapy - Iron or vitamin supplementation: iron, folate, B~12~ - Transfusions for low counts or blood loss **[Anemia -- Implementation]** - Balance physical activity, exercise & rest - Maintain adequate nutrition & perfusion - Patient education to promote compliance with medications & nutrition - Monitor VS & pulse oximetry; supplemental oxygen as needed - Monitor for potential complications **[Anemia -- Complications]** - Heart failure - Angina - Paresthesia's - Reduced oxygenation & perfusion to tissues ischemia & death of tissue - Confusion - Reduced perfusion to brain - Injury related to falls - Hypotension - Depressed mood **[Gerontologic Considerations]** - Anemia is the **most common hematologic condition affecting older patients**, particularly those admitted to hospitals or in long-term care facilities - The impact of even mild anemia on function in older adults is significant & may include decreased physical performance, decreased mobility, increased frailty, increased rates of depression, increased risk for falling, & delirium - Fatigue, dyspnea & confusion may be seen more readily in the older adult who is anemic **[Sickle Cell Disease]** - Can cause severe hemolytic anemia - Inherited RBC disorder (HbS) - Hemoglobin molecule is defective round shape is altered so that it is sickle-shaped - RBCs are hard, sticky, resemble a sickle as blood passes through vessels, the sickle cells will stick to each other & cause occlusions in vessels - Sickled RBCs die early causing shortage of RBCs (sickle cell anemia) & shortage of oxygen carrying capacity - When they travel through small blood vessels, they get stuck and clog the blood flow (very painful) - The only cure for SCD is bone marrow or stem cell transplant - Reserved for severe cases in children with minimal organ damage from SCD - Very risky, serious side effects including death - Usually, best match is sibling **[Sickle Cell Disease -- Assessment]** - Health history & physical exam - **PAIN assessment** - Present in sickle cell crisis - Excruciating pain from anemia & occlusions - Laboratory data: S-shaped hemoglobin (sickle hemoglobin gene) - Presence of symptoms & impact of those symptoms on patient's life; swelling, fever, pain - Sickle cell crisis assessment - Blood loss: menses, potential GI loss, GYN bleed, etc. - Cardiovascular & neurologic assessment - Increased risk for heart attack & stroke from the clumping of RBCs **[Sickle Cell Disease -- Planning & Implementation]** - Hydration (IV fluids) - Oxygen - Pain management - Manage fatigue - Infection prevention - Increased risk of pneumonia, meningitis, bone infections, bloodstream infections - This is due to damage of the spleen from clogging - Promote coping - Often have shortened lifespans & a lot of pain - Education of disease process - Monitor for complications - Crisis: avoid extreme temperatures, high altitude/low oxygen **[Sickle Cell Disease -- Complications]** - Hypoxia, ischemia, infection - Dehydration - Cerebrovascular accident - Anemia - Acute & chronic kidney disease - Heart failure - Impotence - Poor compliance - Substance abuse **[Sickle Cell Disease -- Medications to Treat]** - **HOP** to treatment: - Hydrate IV fluids - Oxygen - Pain management (IV opioids) **[Neutropenia]** - Decreased production or increased destruction of neutrophils (\