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surgical pts/wound
chapter 48 & 50
| Question | Answer |
|---|---|
| antibotic use and surgery | enhance the action of anesthetic agents if taken within 2 wks before surgery, mild resp depression |
| antidysrhythmics | reduce cardiac contractility |
| anticoagulants | d/c 48 hours prior to surgery |
| anticonvulsants | alters metabolism of anesthetic agents |
| antihypertensives | beta blockers and calcium channel blockers interact with anesthesia causing bradycardia, hypotension and impaired circulation. inhibts synthesis and storage of norepi in sympathetic nerve endings |
| corticosteroids | long-term use reduces the ability of the body to withstand stress; increase dosage before and during surgery |
| insulin | stress and IV glucose increase dosage requirements while nutritional intake decreases requirements |
| diuretics | potentiate electrolyte imbalances (potassium) after surgery |
| NSAIDs | prolonged bleeding time |
| herbals: ginger, gingko, ginseng | affect platelet activity and increase susceptibility to post op bleeding; ginseng increases hypoglycemia |
| pts most at risk for latex allergies | children with spina bifida, pts with urogenital abnormalities or spinal cord injuries, health care professionals, workers who manufacture rubber products, pts with allergy to bananas, chestnuts, kiwi |
| RBC | men 4.7-6.1 women 4.2-5.4 |
| Hgb | men 14-18 women 12-18 |
| Hct | men 42-62% women 37-47% |
| WBC | 5000-10000 |
| sodium | 136-145 |
| potassium | 3.5-5 |
| chloride | 95-105 |
| HCO | 22-26 arterial 24-30 venous |
| PT | 11-12.5 sec |
| INR | 0.76-1.27 |
| APTT | 30-40 sec |
| platelets | 150000-400000 |
| creatinine | men 0.6-1.2 women 0.5-1.1 |
| BUN | 10-20 |
| glucose | fasting 70-105 |
| informed consent | physicians responsibility |
| You are the nurse in the preoperative holding area and are preparing the patient for the operating room. You completed all preliminary procedures, storing valuables, checking the preoperative checklist, and assisting the patient to the bathroom. You are preparing to perform the Universal Protocol with patient verification. When is the right time to administer the preoperative sedative? | The sedative should be administered after the Universal protocol is completed because the patient must be alert and able to participate in all three portions of the process. |
| S&S of hemorrhage | ↓BP, ↑HR and resp, thready pulse, cool, clammy, pale skin, restlessness |
| malignant hyperthermia | genetic disorder causing complication of anesthesia |
| S&S of malignant hyperthermia | hypercarbia, tachypnea, tachycardia, PVCs, unstable BP, cyanosis, skin mottling, muscular rigidity, hyperkalemia, elevated temp occurs late |
| glucose levels post op | normoglycemia or <150 |
| wound dehiscence | separation of wound edges at suture line |
| wound evisceration | protrusion of internal organs |
| interventions for malignant hyperthermia | notify surgeon/anesthesiologist immediately, prepare to administer dantrolene sodium (Dantrium), monitor vitals frequently |
| pressure ulcer | a localized injury to the skin and other underlying tissue, usually over a body prominence as a result of pressure and/or shear or friction |
| hyperemia | redness |
| blanching hyperemia | blanches when pressed on - hyperemia is transient and is an attempt to overcome the ischemia |
| stage 1 pressure ulcer | nonblanchable; intact skin |
| stage 2 pressure ulcer | partial-thickness skin loss or blister; shallow open ulcer |
| stage 3 pressure ulcer | full-thickness skin loss - fat visible; may include undermining and tunneling |
| stage 4 pressure ulcer | full-thickness tissue loss - muscle/bone visible; slough or eschar may be present |
| unstageable/unclassified pressure ulcer | full-thickness skin or tissue loss - depth unknown; the depth is completely obscured by slough and/or eschar |
| slough | yellow, tn, gray, green or brown; must be removed before the wound is able to heal |
| eschar | tan, brown, black; needs to be removed before the wound can heal |
| suspected deep-tissue injury | depth unknown; purple or maroon intact skin or blood filled blister |
| granulation tissue | red, moist tissue composed of new blood vessels, indicates progression towards healing |
| wound healing by primary intention | wound that is closed; surgical incision, stapled or sutured wound; healing occurs by epithelialization, heals quickly, minimal scar |
| wound healing by secondary intention | wound edges not approximated; pressure ulcers, surgical wounds that have tissue loss; heals by granulation, contraction and epithelialization |
| wound healing by tertiary intention | wound left open for several days and then the edges are approximated; contaminated wounds; closure is delayed until risk of infection is resolved |
| According to the CDC | a wound is infected if purulent material drains from it even if a culture was not taken or has negative results |
| nursing actions for eviscerated wound | place sterile towel soaked in sterile saline over the tissues, immediately contact the surgical team: this is a surgical emergency, observe for s%s of shock, prepare pt for surgery |
| Braden scale | assesses for risk of pressure ulcers using sensory perception, moisture, activity, mobility, nutrition and friction/shear |
| calories | 30-40 kcal/kg/day must maintain positive nitrogen balance |
| protein | 1-1.5 g/kg/day |
| vitamin C | 100-1000 mg/day |
| vitamin A | 1600-2000 retinol equivalents per day |
| zinc | 15-30 mg |
| fluid | 30-35 mL/kg/day |
| signs of actual or potential nutritional problems | loss of 5% of usual weight, weight less than 90% of ideal body weight, loss of 10 obs in a brief period of time |
| estimating amount of drainage from bandaged wound | 1 g equals 1 mL of drainage |
| the gold standard of wound culture | biopsy |
| proper irrigation pressure is achieved with | 19 gauge needle or catheter and a 35 mL syringe - this will deliver saline to pressure ulcer at 8 psi |
| wet to dry saline gauze dressing for wound debridement | place moistened gauze into the wound and allow the dressing to dry thoroughly before pulling the gauze that has adhered to the tissue out of the pressure ulcer. |
| non-selective method of debridement | devitalized and viable tissues are are removed |
| autolytic debridement | synthetic dressings over a wound to allow the eschar to be self-digested by the action of enzymes that are present in wound fluids: transparent film or hydrocolloid dressings |
| chemical debridement | topical enzyme preparation, dakin's solution or sterile maggots. ewwwww |
| surgical debridement | using scalpel, scissors, or other sharp instrument; indicated when pt has cellulitis or sepsis |
| hydrocolloid dressings | complex formulations of colloids, elastomeric and adhesive components; they are adhesive and occlusive |
| calcium alginate dressings | made from seaweed, come in sheets and rope form, do not use in dry wounds; must have secondary dressing; |
Created by:
nursingTSJC2013
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