Fundamentals 1025 Exam 3 Study Guide PDF

FUNDAMENTALS 1025 LECTURE EXAM 3 ___ Chapter 41 {Oxygenation} Scientific Knowledge Base Respiratory physiology ○ Structure and function ○ Work of breathing ○ Lung volumes ○ Pulmonary circulation Respiratory gas exchange...

FUNDAMENTALS 1025 LECTURE EXAM 3 ___ Chapter 41 {Oxygenation} Scientific Knowledge Base Respiratory physiology ○ Structure and function ○ Work of breathing ○ Lung volumes ○ Pulmonary circulation Respiratory gas exchange : occurs through diffusion ○ Thickness of alveolar capillary membrane affects rate of diffusion; patients with pulmonary edema, pulmonary infiltrates, or pulmonary effusion have a thickened membrane = decreased delivery of oxygen ○ Oxygen transport ○ Carbon dioxide transport Regulation of ventilation TERMS Disturbances in oxygenation often result from ineffective gas exchange (lungs) or an ineffective pump (heart). Oxygen is a basic human need. The cardiac and respiratory systems work together to supply the blood with oxygen necessary for carrying out respiratory and metabolic processes needed to sustain life Blood is oxygenated through ventilation, perfusion, and transport for respiratory gases. The CV system provides transport mechanisms to distribute oxygen to cells and tissues of the body. Respiration: the exchange of oxygen and carbon dioxide during cellular metabolism. Ventilation: act of air and gases moving in and out of the lungs; requires coordination of the muscular and elastic properties of the lungs and thorax. Major inspiratory muscle of respiration is the diaphragm  2 Structure & Function: respiratory muscles, pleural space, lungs, and alveoli essential for ventilation, perfusion, and exchange of respiratory gases. ○ Perfusion: ability of the CV system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs. ○ Conditions that change the structure and function of the pulmonary system alter respiration (i.e., COPD, asthma, lung cancer, and cystic fibrosis). Increased respiratory rate, decreased O2 sat, or adventitious lung sounds. Work of breathing: effort required to expand and contract the lungs; typically quiet and accomplished with minimal effort. ○ COPD patients’ work of breathing is increased due to loss of the elastic recoil of the lungs and thorax ○ Atelectasis: collapse of the alveoli that prevents normal exchange of O2 and CO2 ○ Accessory muscles can increase lung volume during inspiration (COPD & emphysema) ○ Decreased lung compliance, increased airway resistance, and increased use of accessory muscles increase WOB Lung volumes: normal volumes determined by age, gender, and height. ○ Tidal volume: amount of air exhaled following a normal inspiration ○ Residual volume: amount of air left in the alveoli after a full expiration ○ Forced vital capacity: maximum amount of air that can be removed from lungs during forced expiration Pulmonary circulation: primary function is to move blood to and from alveolar capillary membrane for gas exchange. Oxygen transport: consist of lungs and CV system; hemoglobin transports most oxygen Regulation of ventilation: necessary to ensure sufficient O2 intake and CO2 elimination to meet the demands of the body; changes in levels of O2, CO2, and H+ stimulate receptors and regulators to adjust rate and depth of ventilation to maintain normal ABGs. a A A A A  3 Factors Affecting Oxygenation Physiological factors: any condition affecting cardiopulmonary functioning directly affects ability of the body to meet O2 demands ○ Decreased oxygen-carrying capacity ○ Hypovolemia ○ Decreased inspired oxygen concentration ○ Increased metabolic rate Respiratory disorders: include hyperventilation, hypoventilation, and hypoxia. Cardiac disorders: include disturbances in conduction, impaired valvular function, myocardial hypoxia, cardiomyopathy conditions, and peripheral tissue hypoxia. Other: alterations affecting oxygen-carrying capacity (anemia), decreased inspired oxygen concentration, increases in metabolic demand of the body (fever), and alterations affecting chest wall movement caused by musculoskeletal abnormalities or neuromuscular alterations (muscular dystrophy). Decreased oxygen-carrying capacity: hemoglobin carries the majority of oxygen to tissues; anemia and inhalation of toxic substances decreases decreased oxygen-carrying capacity ○ Anemia: pts have fatigue, decreased activity tolerance, increased breathlessness, increased HR, and pallor; physiological response to chronic hypoxemia is development of increased RBCs (polycythemia) ○ Carbon monoxide: colorless, odorless gas that causes decreased oxygen-carrying capacity; hemoglobin binds with CO, creating a functional anemia; headache, dizziness, nausea, vomiting, and dyspnea (goes unnoticed as it mimics other disorders) Hypovolemia: conditions such as shock and severe dehydration cause extracellular fluid loss and reduced circulating blood volume = hypoxia to body tissues; body adapts/compensates by increasing HR to increase blood volume returned to the heart = increased cardiac output Decreased inspired oxygen concentration: leads to decreased oxygen-carrying capacity; caused by upper or lower airway obstruction; decreased environmental oxygen (at high altitudes); or hypoventilation (occurs in opiate overdose) Increased metabolic rate: increases oxygen demand; normal in pregnancy, wound healing, and exercise because the body is using energy for building tissue. ○ When fever persists, metabolic rate remains high, and body begins to break down protein stores = muscle wasting and decreased muscle mass, including respiratory muscles such as the diaphragm and intercostal muscles; body adapts by increasing rate and depth of respiration; WOB increases, and patient displays S/S of hypoxemia  4 Conditions Affecting Chest Wall Movement Pregnancy: enlarging uterus pushes abdominal contents upward against diaphragm; dyspnea on exertion & increased fatigue Obesity: reduced lung volumes from heavy lower thorax and abdomen; obstructive sleep apnea; increased WOB; susceptible to atelectasis after surgery b/c lungs do not fully expand Musculoskeletal abnormalities: abnormal structural configurations, trauma, muscular diseases, diseases of CNS; pectus excavatum, kyphosis, lordosis, scoliosis Trauma: flail chest (multiple rib fractures); incisions; opioids to treat pain of surgery further decrease RR and chest wall expansion Neuromuscular diseases: myasthenia gravis and Guillain-Barre syndrome Central nervous system alterations: diseases/trauma of medulla oblongata and/or spinal cord = impaired ventilation Influences of chronic lung disease: barrel chest occurs due to overuse of accessory muscles and air trapping in COPD or cystic fibrosis = dyspnea, hypoxemia and/or hypercapnia, tachypnea. Alterations in Respiratory Functioning Hypoventilation: Occurs when alveolar ventilation is inadequate to meet the oxygen demand of the body or eliminate sufficient carbon dioxide ○ Atelectasis, COPD (stimulus to breathe is decreased arterial oxygen level = hypoxic drive to breathe) ○ S/S: mental status changes, dysrhythmias, and potential cardiac arrest Hyperventilation: A state of ventilation in which the lungs remove carbon dioxide faster than it is produced by cellular metabolism ○ Severe anxiety, infection, drugs, diabetic ketoacidosis, fever, or acid-base imbalance ○ S/S: rapid respirations, sighing breaths, numbness & tingling of hands/feet, light-headedness, and LOC Hypoxia: Inadequate tissue oxygenation at the cellular level ○ S/S: apprehension, restlessness (early sign), inability to concentrate, decreased LOC, dizziness, behavioral changes, fatigue, agitation, increased pulse rate, increased RR, cyanosis (late sign)  5 Alterations in Cardiac Functioning Disturbances in conduction (dysrhythmias): caused by ischemia, valvular abnormalities, anxiety, drug toxicity, caffeine, alcohol, or tobacco use, or a complication of acid-base/electrolyte imbalance Altered cardiac output ○ Left-sided heart failure (LUNGS): fatigue, breathlessness, dizziness, and confusion due to tissue hypoxia; pulmonary congestion, crackles, hypoxia, SOB, cough, paroxysmal nocturnal dyspnea ○ Right-sided heart failure: SYSTEMIC symptoms such as weight gain, distended neck veins, hepatomegaly, splenomegaly, and dependent peripheral edema Impaired valvular function: acquired or congenital disorder of a cardiac valve resulting in stenosis. (hardening) or regurgitation (impaired closure) Myocardial ischemia ○ Angina: transient imbalance between myocardial O2 supply & demand = chest pain that is aching, sharp, tingling, or burning or that feels like pressure; lasts 3-5 minutes; precipitated by activities like eating heavy meals, exercise or stress) and relieved with rest and coronary vasodilators (nitro) ○ Myocardial infarction/ACS: due to sudden decreases in coronary blood flow or increase in myocardial oxygen demand without adequate coronary perfusion Chest pain associated with MI in men: crushing, squeezing, stabbing; pain often in left chest and sternal area; may be felt in the back; radiates down left arm to the neck, jaws, teeth, epigastric area and back; occurs at rest or exertion and lasts more than 20 minutes; nothing relieves pain CAD: differences between men and women ○ As women get older, risk for heart disease increases, making it the leading cause of death for women ○ Initial symptom is angina; also present with atypical symptoms such as fatigue, indigestion, SOB, and back or jaw pain; twice the risk of dying within the first year after a heart attack than men  6 Nursing Knowledge Base Factors influencing oxygenation Developmental: ○ Young and Middle-age: multiple cardiopulmonary risk factors (unhealthy diet, lack of exercise, stress, OTC and Rx drugs not used as intended, illegal substances, and smoking ○ Older adults: changes of systems associated with calcification of heart valves, valvular stiffening and increased LV wall thickness, fewer SA nodes, and costal cartilage stiffening ⇀ Osteoporosis changes shape and size of thorax ⇀ Trachea and large bronchi enlarged from calcification of airways ⇀ Alveoli enlarge = decreased surface area for gas exchange ⇀ Number of functional cilia decrease = decrease effectiveness of cough mechanism leading to increased risk for respiratory infections Lifestyle factors: ○ Nutrition ○ Hydration ○ Exercise ○ Smoking ○ Substance abuse ○ Stress Environmental: prevalence of COPD higher in rural areas vs. urban; patient’s workplace can increase risk for pulmonary disease (occupational pollutants = asbestos, talcum powder, dust, and airborne fibers)  7 Assessment Through the patient’s eyes Nursing history ○ Health risks, Pain, Fatigue, Dyspnea, Cough, Environmental exposures, Smoking, Respiratory infections, Allergies, Medications Physical examination ○ Inspection ○ Palpation ○ Percussion ○ Auscultation Diagnostic tests: TB Montoux test, thoracentesis, stress tests, imaging studies, labs, sputum specimens/cultures, ABGs, PFTs, PEFR, bronchoscopy \ TERMS Health risks: family hx of lung cancer or CV disease; exposure to TB or asbestos Pain: chest pain, pericardial pain, pleuritic chest pain, musculoskeletal pain Fatigue: sign of worsening chronic underlying process (PQRSTU) Dyspnea: PQRSTU ○ Orthopnea: patient uses multiple pillows when reclining to breathe easier or sits leaning forward with arms elevated Cough: onset, frequency, productive or nonproductive, type and quantity of sputum ○ Hemoptysis: bloody sputum ○ Hematemesis: bleeding associated with GI tract Allergies: airborne allergens (pet dander, pollen, or mold) exposure and response to exposure Nursing Diagnosis Examples of nursing diagnoses when planning care for the patient with alterations in oxygenation Impaired Cardiac Output Acute Pain Activity Intolerance Risk for Activity Intolerance Impaired Airway Clearance  8 Implementation: Health Promotion Vaccinations ○ Influenza, pneumococcal Healthy lifestyle ○ Eliminating risk factors, eating right, regular exercise, stress reduction, smoking cessation, hydration Environmental pollutants ○ Secondhand smoke, work chemicals, asthma triggers, perfumes/colognes, and pollutants Implementation: Acute Care Dyspnea management: dyspnea is difficult to treat; treatment individualized; treat underlying cause followed by other therapies (i.e., medications, oxygen therapy, physical techniques) ○ Bronchodilators, inhaled steroids, mucolytics, low-dose anti-anxiety meds ○ Cardiopulmonary reconditioning (Exercise, breathing techniques, cough control), relaxation techniques, biofeedback, and meditation Airway maintenance: hydration, coughing techniques, suctioning, CPT, nebulizer therapy Mobilization of secretions: repositioning, suctioning Hydration: fluid intake of 1500-2500 ml/day Humidification: process of adding water to gas to keep airways moist (high flow rates >4L/min); sterile water used Nebulization: adds moisture to inspired air by mixing particles of varying sizes with air; improves clearance of pulmonary secretions; administer bronchodilators and mucolytic agents Coughing and deep-breathing: coughing effective for maintaining patent airway; deep-breathing increases air to lower lungs, decreasing dyspnea Chest physiotherapy ○ External chest wall manipulation using percussion, vibration, or high-frequency chest wall compression (HFCWC) ○ Postural drainage: component of pulmonary hygiene; consists of drainage, positioning, and turning and is sometimes accompanied by chest percussion and vibration  9 Positive expiratory pressure PEP: airway clearance technique that can be used with and without oscillation. Reserved for patients with CF or other lung diseases in which sputum is retained. Allows air to be inhaled easily but forces patient to exhale against resistance. This helps air get behind the mucus, which then makes it easier to expectorate the mucus. ★ Maintenance and promotion of lung expansion Ambulation: immobility is a major factor in developing atelectasis, ventilator-associated pneumonia, and functional limitations (muscle weakness & fatigue). Ambulation leads to increase in general strength and lung expansion. Positioning: frequent changes of position reduce stasis of pulmonary secretions and decreased chest wall expansion. 45-degree semi-Fowler’s most effective position to promote lung expansion and reduce pressure from abdomen on the diaphragm. Incentive spirometry: encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume; thought to prevent or treat atelectasis in the post-op patient; recent evidence suggests it is not as effective as it once was thought. Artificial airways Oral airway: prevents obstruction of the trachea by displacement of the tongue into the oropharynx; from teeth to oropharynx Endotracheal and tracheal airways: ET tube is a short-term artificial airway used to administer invasive mechanical ventilation, relieve upper airway obstruction, protect against aspiration, or clear secretions (from mouth to trachea) ○ Long-term assistance with tracheostomy that requires a surgical incision Invasive mechanical ventilation: positive-pressure ventilation; life-saving technique used with artificial airways (ET or tracheostomy) ⇀ Invasive mechanical ventilation indications: supporting cardiopulmonary gas exchange, increasing lung volume, and reducing work of breathing; reversing hypoxia and acute respiratory acidosis, relieving respiratory distress, preventing or reversing atelectasis and respiratory muscle fatigue, allowing for sedation and/or other neuromuscular blockade, thereby decreasing oxygen consumption, and stabilizing chest wall; can fully or partially replace spontaneous breathing ○ VAP is a significant potential complication (HAI) Noninvasive ventilation: maintains positive airway pressure and improves alveolar ventilation ⇀ Noninvasive ventilation: used to treat obstructive sleep apnea, respiratory failure, and following extubation of an ET; reduces and reverses atelectasis, improves oxygenation, reduces pulmonary edema, and improves cardiac function; reduces risk of atelectasis (CPAP and BiPAP)  10 Chest tubes: catheter inserted through rib cage into pleural space to remove air, fluids, or blood; to prevent air or fluid from reentering pleural space; or to reestablish normal intrapleural and intrapulmonic pressures after trauma or surgery ⇀ Chest tubes: common after chest surgery and chest trauma and are used for treatment of pneumothorax or hemothorax ○ Pneumothorax: collection of air in the pleural space which can lead to collapsed lung; causes can be chest trauma (e.g., stabbing, gunshot wound, or rib fracture; rupture of an emphysematous bleb on the surface of the lung, tearing of the pleura from an invasive procedure, insertion of subclavian IV line, and invasive mechanical ventilation; spontaneous pneumothorax can occur in young, healthy individuals or in patients with COPD or CF. ○ Tension pneumothorax: life-threatening condition in which air enters pleural space and cannot escape; S/S include dyspnea, tachycardia, tracheal deviation laterally, and absent breath sounds on affected side ○ Hemothorax: accumulation of blood and fluid in pleural space, usually as a result of trauma; can also be caused by pneumonia or TB; S/S include pain and dyspnea, shock if blood loss is severe Special considerations: watch for slow, steady bubbling in water seal chamber and keep it filled with sterile water at the prescribed level; constant or intermittent bubbling in water-seal chamber, or new more vigorous bubbling indicates a leak in the drainage system or another pneumothorax; mark levels every shift and report unexpected cloudy or bloody drainage ○ Routinely evaluate O2 sat levels, RR, breath sounds, and insertion site for subcutaneous emphysema (presence of air under the skin, and palpable crepitus) ○ Semi-Fowler or high-Fowler position ○ Encourage patient to cough, use IS, and breathe deeply  11 Maintenance and promotion of oxygenation ○ Oxygen therapy ○ Safety precautions: oxygen is highly combustible; use only when prescribed; keep tanks secure and store upright and either chained or secured to holders ○ Supply of oxygen: tanks or wall ○ Methods of oxygen delivery ⇀ Nasal cannula: flow rate of 1-6 L/min; greater than 4 L/min requires humidification ⇀ High flow nasal cannula: provides heated, humidified oxygen at flow rates as high as 60 L/min ⇀ Oxygen masks: simple mask 6-12 L/min; mask contraindicated in carbon dioxide retention (flow rates should be greater than 6 L/min); partial rebreather and nonrebreather have a reservoid to deliever 10-15 L/min; Venturi mask delivers high-flow O2 4-12 L/min (COPD) Restoration of cardiopulmonary functioning ○ Cardiopulmonary resuscitation: 100-120 compressions/minute 2 inches deep Implementation: Restorative & Continuing Care Respiratory muscle training: improves muscle strength and endurance, resulting in improved activity tolerance; repetitive breathing exercises against some external force/load (IS) Breathing exercises: techniques to improve ventilation and oxygenation Pursed-lip breathing: involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse (COPD) Diaphragmatic breathing: useful for patients with pulmonary disease and dyspnea secondary to heart failure; increases tidal volume and decreases RR, leading to improved breathing pattern and quality of life Home oxygen therapy: indications PaO2 of 55 mm Hg or less or arterial oxygen saturation of 88% or less on RA at rest, on exertion, or with exercise; NC or face mask  12 Chapter 42 {Fluid, Electrolyte, and Acid-Base Balance} Intro Fluid is inside and surrounds all the cells in the body; contains electrolytes (Na & K) and has a degree of acidity. ○ NA = SODIUM ○ K = POTASSIUM Fluid, electrolyte, and acid-base balances within the body maintain the health and function of all body systems. ★ Characteristics of body fluids include the ○ fluid amount (volume), ○ concentration (osmolality) ○ composition (electrolyte concentration) ○ degree of acidity (pH). Scientific Knowledge Base Intravascular fluid: liquid part of the blood (i.e., plasma) Interstitial fluid: located between the cells and outside the blood vessels Transcellular fluids: cerebrospinal, pleural, peritoneal, and synovial fluids; secreted by epithelial cells Osmolality: measure of the number of particles per kilogram of water. Some particles pass easily through cell membranes, others cannot. Isotonic: a fluid with the same tonicity as normal blood Hypotonic: solution that is more dilute than blood Hypertonic: a solution that is more concentrated than normal blood Movement of Water & Electrolytes Active transport: allows cells to maintain their high intracellular electrolyte concentration Requires energy in the form of adenosine triphosphate (ATP) to move electrolytes across cell membranes against the concentration gradient (low to high) E.g. sodium potassium pump (sodium out of a cell and potassium into it) Diffusion: passive movement of electrolytes or other electrolytes down a concentration gradient (high to low) Requires proteins that serve as ion channels  13 Osmosis: process by which water moves through a membrane that separates fluids with different particle concentrations Cell membranes are semipermeable, which means water crosses easily Filtration: allows fluid to move into and out of capillaries (b/w vascular and interstitial compartments) Fluid Balance ★ Fluid intake: occurs orally through drinking but also through eating; avg intake is 2300 mL ○ Thirst control mechanism located within the hypothalamus Fluid distribution: movement of fluid among its various compartments; occurs by osmosis b/w ECF and ICF; occurs by filtration b/w vascular and interstitial parts of ECF ★ Fluid output: occurs through skin, lungs, GI tract, and kidneys (insensible loss through the skin and lungs is continuous) ○ Abnormal output: vomiting, wound drainage, or hemorrhage ○ Increased insensible loss during a fever (diaphoresis) EXCESS SWEATING ○ Antidiuretic hormone: regulates osmolality of the body fluids by influencing how much water is excreted in urine ○ Renin-angiotensin-aldosterone system: regulates ECF volume by influencing how much Na+ and water are excreted in urine; contributes to regulation of BP ○ Atrial natriuretic peptide: regulates extracellular fluid volume by influencing how much Na+ and water are excreted in urine; weak hormone that increases the loss of Na+ and water in the urine  14 Fluid Imbalance Extracellular volume imbalances Deficit: too little isotonic fluid; output of isotonic fluid exceeds intake of sodium-containing fluid ○ Term hypovolemia used; decreased vascular volume Excess: too much isotonic fluid; intake of sodium-containing isotonic fluid has exceeded fluid output Osmolality imbalances Hypernatremia: also called “water deficit”; hypertonic ○ Caused by loss of more water than salt or gain of relatively more salt than water (too much salt = not enough water) ○ Hypernatremia: causes water to move from the tissues into the bloodstream, which can cause the cells to shrink. ○ Salt (also called sodium) makes your body hold onto fluid. This means your heart must work harder to pump around the extra fluid in the body. In heart failure, eating too much salt can worsen symptoms such as swelling, bloating and shortness of breath. Hyponatremia: also called “water excess”; hypotonic ○ Caused by gain of more water than salt or loss of more salt than water (too little salt = increase of water) Clinical dehydration ECV deficit and hypernatremia combined I’S & O’S Intake and absorption ○ Food ○ Fluid Output ○ Urine, feces, and sweat ○ Vomiting, drainage tubes, and fistulas When electrolyte output increases, electrolyte intake must increase to maintain electrolyte balance; if electrolyte output decreases (i.e., oliguria), electrolyte intake must also decrease  15 Electrolyte Imbalances Potassium (K+) Hypokalemia: abnormally low potassium; results from decreased potassium intake and absorption; shift of potassium from ECF into cells, and an increased potassium output Common causes: diarrhea, repeated vomiting, and use of potassium-wasting diuretics S/S: muscle weakness and potentially life-threatening cardiac dysrhythmias Hyperkalemia: abnormally high potassium; results from increased potassium intake and absorption, shift of potassium from cells into ECF, and decreased potassium output Common causes: oliguria: low urinary output ★ S/S: muscle weakness, potentially life-threatening cardiac dysrhythmias, and cardiac arrest Calcium (Ca2+) Hypocalcemia: abnormally low calcium in blood Common causes: acute pancreatitis S/S: increased neuromuscular excitability Hypercalcemia: abnormally high calcium in blood; results from increased calcium intake and absorption, shift of calcium from bones into the ECF, and decreased calcium output Common causes: cancers S/S: weakened bones, pathological fractures, decreased muscular excitability, lethargy Magnesium (Mg2+) Hypomagnesemia: S/S = similar to hypocalcemia; increased neuromuscular excitability, nausea, and vomiting Hypermagnesemia: S/S = decreased muscular excitability, lethargy, and decreased DTRs Normal Electrolyte Ranges Sodium (Na+): 136 – 145 mEq/L Potassium (K+): 3.0 – 5.0 mEq/L Magnesium (Mg2+): 1.3 – 2.1 mEq/L Calcium (Ca2+): 9.0 – 10.5 mg/dL  16 Acid-Base Imbalances Respiratory acidosis: The lungs are unable to excrete enough CO2; arises from alveolar hypoventilation Kidneys compensate by increasing excretion of metabolic acids in urine, increasing blood bicarbonate Respiratory alkalosis: The lungs excrete too much carbonic acid; arises from alveolar hyperventilation Short-lived, so kidneys do not have time to compensate Can cause excitement, confusion, and paresthesia; if pH rises enough, CNS depression can occur ★ Metabolic acidosis: Occurs from an increase of metabolic acid or a decrease of base Respiratory system compensates by hyperventilation; S/S decreased LOC Metabolic alkalosis: Occurs from a direct increase of base ( ) or a decrease of metabolic acid Common causes: vomiting and gastric suction Respiratory system compensates by hypoventilation Assessment Through the patient’s eyes: when a patient is alert enough to discuss care, conduct a patient-centered assessment ○ Ask about previous experiences with imbalances and iv therapy Nursing history ○ Age: very young and old at risk ○ Environment: excessively hot? = increased fluid output (sweating) = hypernatremia, ECV deficit, or clinical dehydration ⇀ Environment: ask about exercise and level of physical work, and if it is in a hot environment ★ Dietary intake: fluids, salt, foods rich in potassium, calcium, and magnesium ⇀ Dietary Restrictions: ask patients about weight-loss diets and diets with high fat and no carb content which can lead to metabolic acidosis; assess patient’s ability to chew and swallow ○ Lifestyle: alcohol intake history; chronic ETOH use can cause hypomagnesemia ○ Medications: include over-the-counter (OTC) and herbal, in addition to prescription medications ⇀ Medications: antacids can cause ECV excess; laxatives = frequent loose stools = removed fluid and electrolytes  17 Medical history Recent surgery (physiological stress) Surgery: in the first 24-48 hrs after surgery, increased secretion of aldosterone, glucocorticoids, and ADH cause increased ECV, decreased osmolality, and increased potassium excretion Gastrointestinal output: increased output of fluid through GI tract GI tract: vomiting and diarrhea can cause ECV deficit, hypernatremia, clinical dehydration, and hypokalemia; chronic diarrhea can cause hypocalcemia and hypomagnesemia; removal of gastric acid through vomiting or NG suction can cause metabolic alkalosis; diarrhea, intestinal suction, or fistula removes bicarbonate and can cause metabolic acidosis Acute illness or trauma ○ Respiratory disorders: predispose pts to respiratory acidosis (i.e., bacterial pneumonia) ○ Burns: high risk for ECV deficit and fluid loss; leads to hyperkalemia and metabolic acidosis ○ Trauma: hemorrhage causes ECV deficit; crush injuries cause hyperkalemia; head injury alters ADH secretion = diabetes insipidus which leads to dilute urine and hypernatremia; head injury can also cause SIADH causing excess ADH and hyponatremia SIADH: Syndrome of inappropriate anti-diuretic hormone secretion; a condition in which the body makes too much antidiuretic hormone (ADH). This hormone helps the kidneys control the amount of water your body loses through the urine. SIADH causes the body to retain too much water. Chronic illness ○ Cancer: hypercalcemia ○ Heart failure: ECV excess and risk of hypokalemia ○ Oliguric renal disease: ECV excess, hyperkalemia, hypermagnesemia, hyperphosphatemia, and metabolic acidosis  18 Physical Assessment Daily weights Indicator of fluid status Use same conditions: Same time of day, same scale after void; wear same clothes Important with CHF Fluid intake and output (I&O) 24-hour I&O: compare intake versus output Intake includes all liquids eaten, drunk, or received through IV Output = Urine, diarrhea, vomitus, gastric suction, wound drainage Laboratory values: Review and compare with normal ranges Vascular Access Devices Blood transfusion Blood groups and types Autologous transfusion: collection and reinfusion of a patient’s own blood; obtained up to 6 weeks before a scheduled surgery Transfusing blood: teach patients to report side effects such as chills, dizziness, or fever once transfusion begins Pretransfusion assessment includes baseline vitals ; stay with patient the first 15 minutes Checked by two RNs 18 G or 20 G IV Transfused over 2-4 hours (unless its an emergency = free flow) Transfusion reactions: adverse event Stop infusion immediately, keep IV line open by running NS at a slow rate; DO NOT turn off the blood and turn on NS that is connected to Y-Tubing ★ CHANGE OUT ALL TUBING Notify HCP, remain with patient and monitor; prepare to administer emergency medications or perform CPR; save blood, tubing and labels etc. Objectives: increasing circulating blood volume after surgery, trauma, or hemorrhage, increasing number of RBCs and maintaining hemoglobin levels in patients with severe anemia, and providing selected cellular components as replacement therapy (i.e., clotting factors, platelets, albumin) Transfusion reaction: an immune response to the transfused blood components in which the patient’s antibodies trigger RBC destruction People with O- blood are universal blood donors People with AB+ blood are universal blood recipients  19 Interventions Interventions for electrolyte imbalances Support prescribed medical therapies Aim to reverse the existing acid-base imbalance Provide for patient safety to prevent falls (lethargy from hypercalcemia and muscle weakness) Educate patients on the reasons for their therapies Interventions for acid-base imbalances Maintain functional IV line and check orders frequently for new medications or fluids ★ Side rails for decreased LOC; support compensatory hyperventilation for patients with metabolic acidosis by keeping oral mucous membranes moist and positioning them to facilitate chest expansion Arterial blood gases: reveals acid-base status and adequacy of ventilation and oxygenation  20 Chapter 50 {Care of Surgical Patients} Peri-Operitave Stages 1. PRE-OP 2. INTRA-OP 3. POST-OP Scientific Knowledge Base Surgical Risk Factors ○ Smoking: higher risk for developing pneumonia, atelectasis, and delayed wound healing ⇀ Increases risk of aspiration ○ Age: very young and older patients at greater surgical risk as a result of immature or a declining physiological status ⇀ Older patients: diminished cardiac, pulmonary, and renal function which decreases ability to maintain homeostasis; postural hypotension and dizziness = increased fall risk ○ Increased risk for aspiration, infection, and bronchospasm; increased risk for dehydration and fluid imbalance ○ Nutrition ○ Obesity: increased risk for atelectasis, pneumonia, and death ⇀ Risk for impaired mobility = increased risk for VTE ⇀ Increased risk for wound infection, blood loss, pressure injuries, dehiscence(the surgial site opens), and evisceration (the organs fall out of the site) ○ Obstructive sleep apnea (OSA): anesthesia may worsen this condition and increase risk of death ○ Immunosuppression: increased risk for infection ○ Fluid and electrolyte imbalance ○ Postoperative nausea and vomiting (PONV) ○ Venous thromboembolism (VTE) Anesthesia involves risk even in healthy patients; however, some patients, including but not limited to those with metabolic and cardiac dysfunction, are at higher risk. One common risk factor for all patients is the surgical stress response PONV: can lead to pulmonary aspiration, dehydration, and arrhythmias resulting from fluid and electrolyte imbalance; vomiting frequently increases risk of dehiscing surgical sutures  21 ○ Patients predisposed: women, individuals with hx of PONV or motion sickness, nonsmoking status, and younger age DVT: is considered a never event after total knee and hip surgery; Medicare and some private insurance companies withhold payment to hospitals because DVTs are preventable ★ Patients at risk: surgical procedures with general anesthetic, surgical time of more than 90 minutes, or 60 minutes if surgery involves the pelvis or lower limb; acute surgical admissions with inflammatory or intraabdominal conditions; those expected to have significant reduction in mobility after surgery ○ Higher risk with following risk factors: ⇀ Active cancer or cancer treatment ⇀ Age over 60 years ⇀ Critical care admission ⇀ Dehydration ⇀ Known clotting disorders ⇀ Obesity Nursing Knowledge Base Perioperative communication ○ Hand-off communication ○ Transitions increase patient’s risk for injuries, missed care, and errors in translating information Glycemic control and infection prevention ○ Poor glucose control increases risk for wound infection and mortality Pressure injury prevention ○ Intrinsic risks (inside): patient’s tolerance to a pressure injury insult ⇀ Intrinsic risks: altered nutrition, decreased mobility, older age, decreased mental status, infection, incontinence, impaired sensory perception, and co-morbidities such as diabetes, malnutrition, and weight ○ Extrinsic risks (outside): variables that increase tissue susceptibility to sustain external pressure ⇀ Extrinsic risks: temperature, friction and shearing forces, and moisture ○ OR risk factors ⇀ OR risk factors: length of surgery, position on OR table, positioning devices used, warming devices, anesthetic agents, intraoperative hemodynamics, and length of time on OR bed  22 Pre-op Surgical Phase: Assessment Nursing history ○ Include information about advance directives, power of attorney, and living wills Medical history ○ Screen for conditions that increase surgical risks ○ Includes past illnesses and surgeries, and primary reason for seeking medical care ○ Ask about family history of anesthetic complications (malignant hyperthermia is an inherited and life-threatening condition) Surgical history ○ Check for complications in prior surgeries ○ History of post-op complications ○ Reports of severe anxiety before a previous surgery Risk factors ○ Knowledge provides focus for the preoperative assessment ○ Screen patients carefully ○ Take necessary precautions ○ Collaborate with health care provider ○ Obstructive sleep apnea: use STOP-BANG assessment tool to screen patients ○ Detailed nutritional assessment Medications ○ Inpatient vs. outpatient ○ (NO BLOOD-THINNERS) Allergies ○ Medications, topical agents, latex, food Smoking habits: plan for aggressive pulmonary hygiene (frequent turning, deep breathing, coughing, and I/S Alcohol ingestion and substance use and abuse: AUDIT tool Pregnancy: ask for LMP; pregnancy test usually done Perceptions and knowledge regarding surgery Support sources: primary caregiver and support person Occupation: anticipate possible effects of surgery on recovery, time it will take to return to work, and eventual work performance Preoperative pain assessment: describe perceived tolerance to pain, past experiences, and prior successful interventions Review of emotional health: surgery is psychologically stressful and can create anxiety Self-concept Body image  23 Coping resources Cultural and spiritual factors Pre-op Surgical Phase: Diagnosis Common nursing diagnoses relevant to the patient having surgery include: ○ Impaired Skin Integrity ○ Risk for Infection ○ Impaired Mobility related to incisional pain ○ Impaired Mobility related to decreased muscle strength ○ Impaired Airway Clearance ○ Anxiety ○ Acute Pain Pre-op Surgical Phase: Implementation Informed consent ○ Surgical procedures require documentation of consent ★ Report any concerns about the patient’s understanding of the surgery to the operating surgeon or anesthesia provider Privacy and social media ○ Do not discuss confidential patient information in public areas or use social media to convey patient information; posting patient information and photos on websites is prohibited Acute care ○ Minimizing risk for surgical wound infection ⇀ Antibiotics ⇀ Skin antisepsis ⇀ Clipping instead of shaving hair ○ Maintaining normal fluid and electrolyte balance ⇀ Fasting before surgery ⇀ IV fluid replacement ⇀ Parenteral nutrition ○ Preventing bowel incontinence and contamination ⇀ Bowel preparations ○ Preparation on the day of surgery ⇀ Hygiene ⇀ Preparation of hair and removal of cosmetics ⇀ Removal of prostheses ⇀ Safeguarding valuables ⇀ Preparing the bowel and bladder ⇀ Vital signs  24 ⇀ Prevention of DVT: Antiembolism devices ⇀ Administering preoperative medications ⇀ Documentation and hand-off ⇀ Eliminating wrong site and wrong procedure surgery Pre-anesthesia Care Unit Preanesthesia care unit (PCU) or pre-surgical care unit (PSCU) (holding area) ★ PCU nurse ⇀ Inserts IV catheter (if not already present) ⇀ Administers preoperative medications ⇀ Monitors vital signs ⇀ Inserts catheter Intraoperative Surgical Phase Nursing process ○ Assessment: circulating nurse assess patient and focuses on immediate clinical status, skin integrity, and joint function ★ Nursing diagnosis: Impaired Airway Clearance, Risk for DVT, Risk for Impaired Skin Integrity, etc. Post-op Surgical Phase Immediate postoperative recovery (Phase I) ○ Hand-off communication ○ Conduct complete systems assessment ○ Once awake, expectorate the airway ○ Airway obstruction ○ Determine a patient’s status and eventual readiness for discharge from the PACU on the basis of vital sign stability ○ Post-anesthesia recovery score (PARS) Recovery in ambulatory surgery (Phase II) ○ After patients stabilize and no longer require close monitoring ○ Promotes a patient’s and family’s comfort and well-being until discharge ○ Nurses continue to monitor patient’s vital signs and level of responsiveness but not at the same intensity as Phase I  25 Inpatients: Post-op Recovery & Convalescence Nursing Process Assessment ○ Prepare the bed and room and have all supplies needed ○ Monitor vital signs according to institution policy ⇀ Typically every 15 minutes x2, every 30 minutes x2, hourly for 2 hours, and then every 4 hours or per orders ○ Through the patient’s eyes: assess expectations for recovery and pain management ★ Airway and respiration: maintain patent airway; assess O2 Sat, RR, rhythm, depth of ventilation, symmetry of chest wall movement, breath sounds, and color of mucous membranes ○ Circulation: HR and rhythm, BP; ECG after surgery; capillary refill, pulses, and color/temperature of nail beds and skin ○ Temperature control: monitor temperature closely ⇀ Malignant hyperthermia: life-threatening ⇀ High CO2 levels, metabolic and respiratory acidosis, increased O2 consumption, production of heat, high serum K+, multiple organ dysfunction and failure ○ Fluid and electrolyte balance Signs of hemorrhage (internal or external): hypotension, tachycardia, tachypnea, thready pulse, cool, clammy, pale skin, and restlessness ○ Notify surgeon ○ Maintain IV infusion ○ Monitor vital signs Q15 minutes or more frequently ○ Continue O2 therapy ★ Early signs of malignant hyperthermia: tachypnea, tachycardia, heart arrhythmias, hyperkalemia, hypercarbia, and muscular rigidity ○ Late signs: elevated temperature, myoglobinuria, and multiple organ failure ○ First S/S occur in OR ○ May occur in early pos—op period Inpatients: Post-op Recovery & Convalescence Neurological functions: level of orientation, pupil and gag reflexes, hand grips, movement of extremities, sensation to touch Skin integrity and condition of the wound Metabolism: monitor glucose levels  26 Genitourinary function: some patients do not regain voluntary control for 6-8 hours ○ Palpate for bladder distention or use bladder scanner Gastrointestinal function: anesthetics slow motility and can cause nausea ○ Manipulation of intestines during abdominal surgery impairs peristalsis ○ Faint or absent bowel sounds typical immediately after surgery ○ Inspect for abdominal distention = gas ○ Return of flatus is more indicative of normal bowel function return Mobility: necessary to promote respiratory, circulatory and gastrointestinal function ○ Early ambulation prevents hospital-acquired conditions and helps to promote bowel function Comfort and sleep Post-op Recovery & Convalescence: Diagnosis Nursing diagnoses for postoperative patients include: Risk for Impaired Skin Integrity Impaired Airway Clearance Risk for Infection Impaired Mobility Impaired Skin Integrity Acute Pain Post-op Recovery & Convalescence: Implementation Acute care ○ Maintaining respiratory function: positioning; I/S; early ambulation allows chest wall expansion and stimulates increased RR (also increases peristalsis) ○ Preventing circulatory complications: prescribe pain medications as ordered to promote early ambulation which promotes venous return and blood flow ⇀ Leg exercises ⇀ Compression stockings ⇀ Administer anticoagulants as ordered ⇀ Promote adequate fluid intake ○ Promoting early mobility: associated with improved outcomes ○ Achieving rest and comfort ○ Temperature regulation  27 ○ Maintaining neurological function: deep breathing and coughing for retained anesthetic gases; monitor LOC ○ Maintaining fluid and electrolyte balance ○ Promoting normal gastrointestinal function and adequate nutrition ⇀ Progressive diet after surgery ⇀ Promote ambulation and exercise = increased peristalsis and promotes return of bowel function ⇀ Maintain adequate fluid intake ○ Promoting urinary elimination: assess for bladder distention and monitor I&Os ○ Skin and wound care: change dressings 5 (IV) - 30 (oral) minutes after giving pain medication, depending on route ○ Maintaining/enhancing self-concept: provide privacy during dressing changes, maintain patient hygiene, maintain a pleasant environment, offer chances for patient to discuss feelings about appearance, fears, or concerns Restorative and continuing care ○ Prepare for discharge ○ Provide patient education ⇀ Medications, wound care, nutrition, etc. ○ Prepare for follow-up appointments ○ Help patients adhere to exercise programs ○ Make referrals to home care as needed “He gives strength to the weary and increases the power of the weak. Even youths grow tired and weary, and young men stumble and fall; but those who hope in the LORD will renew their strength. They will soar on wings like eagles; they will run and not grow weary, they will walk and not be faint.”Isaiah 40:29-31