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EXAM 1 MED SURG
WOUNDS, COMPLICATIONS, MEDICATIONS, ANESTHESIA
| Question | Answer |
|---|---|
| Medications to ask about | Corticosteroids, diuretics, phenothiazines, tranquilizers, insulins, anticoagulants, anticonvulsants, thyroid hormones, opioids |
| The use of Corticosteroids Poses what risk during surgery | Cardiovascular collapse if discontinued suddenly. So, a bolus will be needed via IV immediately before and after surgery |
| The use of Diuretics Poses what risk during surgery | During anesthesia, they may cause excessive respiratory depression resulting from associated electrolyte imbalances |
| The use of Phenothiazines Poses what risk during surgery | May increase the hypotensive action of anesthetics |
| The use of Tranquilizers Poses what risk during surgery | May cause anxiety, tension, and even seizures if withdrawn suddenly |
| The use of Insulins Poses what risk during surgery | Interactions with anesthetics should be considered. Meds may be given IV to keep blood glucose within normal range |
| The use of Anticoagulants Poses what risk during surgery | Can increase the risk of bleeding during intraoperative and postoperative periods. Should be discontinued in anticipation of surgery. Surgeon will determine for how long before surgery the patients should stop taking the med. |
| The use of Anticonvulsants Poses what risk during surgery | IV meds may be needed to keep seizures under control in the intraoperative and postoperative periods |
| The use of Thyroid Hormones Poses what risk during surgery | IV administration may be needed during post op to maintain thyroid levels |
| The use of Opioids Poses what risk during surgery | Long-term use for chronic pain in the preoperative period may alter the patient's response to analgesic agents |
| General Anesthesia Stage I | Beginning Anesthesia- Dizziness and a feeling of detachment, possible ringing, roaring, or buzzing in ears. Still conscious, but may sense an inability to move the extremities easily. Can result in agitation. Noises are exaggerated, even low voices or minor sounds seem loud and unreal. |
| General Anesthesia Stage II | Excitement - Characterized variously by struggling, shouting, talking, singing, laughing, or crying is often avoided if IV agents are given smoothly and quickly. Pupils dilate, but they construct when exposed to light, pulse is rapid, respirations may be irregular. |
| General Anesthesia Stage III | Surgical Anesthesia - Reached by administration of anesthetic vapor or gas and supported by IV agents as necessary. The patient is unconscious and lies quietly on the table. Pupils are small but constrict when exposed to light. Respirations are regular, pulse rate and volume are normal. Skin is pink or slightly flushed |
| General Anesthesia Stage IV | Medullary Depression - Reached if too much anesthesia has been given. Respirations become shallow, pulse is weak and thready, pupils become widely dilated and no longer constrict when exposed to light. Cyanosis develops and without prompt intervention, death rapidly follows. If this occurs, the anesthetic agent should be d/c immediately and respiratory and circulatory support is initiated |
| Regional Anesthesia | When an agent is injected around nerves so that the region supplied by these nerves is anesthetized. The patient is awake and aware of surroundings unless medications are given to produce mild sedation or relieve anxiety. Be sure to be cautious of careless conversation, unnecessary noise, and unpleasant odors. |
| Local Anesthesia | Injection into tissues at the planned incision site. Works by blocking the nerves immediately supplying the area. Given directly to surgical field and the circulating nurse observes and monitors the patient for possible side effects. It is simple, economical, nonexplosive, equipment needed is minimal, postoperative recovery is brief, undesirable effects of general anesthesia are avoided, and it is ideal for short and minor surgical procedures |
| Moderate Sedation | Conscious sedation. IV form of sedative or analgesic meds to reduce patient anxiety and control pain during procedures. Goal is to depress LOC to enable procedure. The patient is able to maintain patent airway, retain protective airway reflexes and respond to verbal and physical stimuli |
| Monitored Anesthesia Care | are needed to manage the effects of a level of deeper sedation to return the patient to appropriate level of sedation. This is used in healthy patients undergoing relatively minor surgical procedures and for some critically ill patients who may be unable to tolerate anesthesia without extensive invasive monitoring and pharmacologic support |
| Prevention of Central Line Associated Bloodstream Infections (CLABSI) | Aseptic technique and sterile techniques, immediately change sterile dressing or every 2 days, promptly remove lines that are no longer needed. |
| Prevention of Catheter Associated Urinary Tract Infections (CAUTI) | Insert appropriate catheter, use aseptic technique with sterile equipment, remove as soon as possible, maintain unobstructed downward flow. |
| Prevention of Hospital Acquired Pressure Ulcers | Keep skin dry, turn patient every 2 hours, skin inspection every shift, patient education, assess for poor tissue perfusion, |
| Post Op Priorities | Maintain patient's airway, monitor respiratory and cardiovascular function, and vital signs. monitor skin color, LOC, and ability to respond to commands. |
| Shock causes | Hypovolemia and decreased intravascular volume |
| Types of shock | Hypovolemic, cardiogenic, neurogenic, anaphylactic, and septic |
| Hypovolemic shock | The most common. Symptoms include pallor, cool moist skin, rapid breathing, cyanosis of lips, gums, and tongue. Rapid, weak, thready pulse, narrowing BP, low BP, and concentrated urine. |
| Post Op Respiratory Complications | Atelectasis, pneumonia, PE, aspiration |
| Post Op Cardiovascular Complication | Shock, Thrombophlebitis |
| Post Op Neurological Complications | Delirium, Stroke |
| Post Op Skin/Wound Complications | Breakdown, infection, dehiscence, evisceration, delayed healing, hemorrhage, hematoma |
| Post Op GI Complications | Constipation, Paralytic Ileus, bowel obstruction |
| Post Op GU Complication | Acute urine retention, UTI |
| Post Op Functional Complications | Weakness, fatigue, functional decline |
| Post Op Thromboembolic Complication | DVT, PE |
| Malignant Hyperthermia | Rare inherited muscle disorder that is chemically induced by anesthetic agents. Can be triggered by myopathies, emotional stress, heatstroke, neuroleptic malignant syndrome, strenuous exercise exertion, and trauma. Susceptible people include those with strong bulky muscles, history of muscle cramps, weakness, and unexplained temp elevation |
| Anesthesia Awareness | Indications of the occurrence of anesthesia include an increase in BP, HR, and patient movement. Hemodynamic changes can be masked by paralytic medication, beta-blockers, and calcium channel blockers, thus the awareness may remain undetected. |
| Nausea/Vomiting | If gagging occurs, patient is turned to the side, and head of table is lowered, and basin is provided. Suction is used to remove saliva and gastric contents. Sometimes antiemetics are given preoperatively to counteract possible aspiration. Aspiration leads to bronchial spasms and wheezing. |
| Anaphylaxis | Can occur from many medications, latex, or other substances. Reaction can be immediate or delayed |
| Hypoxia/Respiratory Complications | Pneumonitis and pulmonary edema can develop from aspiration and lead to extreme hypoxia. The volume and acidity of the aspirate would determine the extent of damage to the lungs. Inadequate ventilation, occlusion of the airway, inadvertent intubation of the esophagus are all possible with general anesthesia |
| Hypothermia | Temp may fall, and glucose metabolism is reduced and may result in metabolic acidosis can occur from low OR temp, infusion of cold fluids, inhalation of cold gases, and open body wounds or cavities, decreased muscle activity, advanced age, or pharmaceutical agents. |
| Pathophysiology & Clinical Manifestations of Malignant Hyperthermia | Related to a hypermetabolic condition that involves altered mechanisms of calcium function in skeletal muscle cells. Initially affects the cardiovascular & respiratory system, and abnormal musculoskeletal activity. Tachycardia, dysrhythmias, hypotension, decreased cardiac output, oliguria, hypercapnia, muscle rigidity, and eventually cardiac arrest. Body temp may raise 2-4 degrees every 5 minutes |
| Medical Management of Malignant Hyperthermia | Early recognition. Decrease metabolism, reverse metabolic and respiratory acidosis, correct dysrhythmias, decrease body temp, provide oxygen and nutrition to tissue, and correct electrolyte imbalances. Anesthesia and surgery should be postponed. Unless a different anesthetic is available. It typically manifests 10-20 minutes after induction but can occur up to 24 hours after surgery |
| Nursing Management of Malignant Hyperthermia | Identifying patients at risk, recognizing signs and symptoms, have appropriate medication and equipment available, and be knowledgeable about the protocol to follow |
| How to maintain asepsis and Rational | Must wear long-sleeved, sterile gloves and gowns. Masks, antiseptic solution is applied to large areas of the skin that will be used in the surgery, hair removal is done immediately before procedure with electric clippers to minimize risk of infection. Remainder of the patient's body is covered with sterile drapes. |
| Preventing Wound Dehiscence and who is at increased risk? | Disruption of surgical incision or wound, either from marked distension or strenuous cough, elderly, anemia, poor nutritional status, obesity, malignancy, diabetes, use of steroids. |
| Evisceration | Sudden rupture of a wound, with coils of intestine pushed out. Extremely painful and is often associated with vomiting |
| Venous Thromboembolism (VTE, DVT, PE, Prophylactic Treatment) | Low dose heparin, low dose warfarin, early ambulation. |
| Class I = Clean | An uninfected operative wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tract is not entered. In addition, clean wounds are primarily closed and, if necessary, drained with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria. |
| Class II = Clean/Contaminated | An operative wound in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered. |
| Class III = Contaminated | Open, fresh, accidental wounds. In addition, operations with major breaks in sterile technique (eg, open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in which acute, no purulence, inflammation is encountered are included in this category. |
| Class IV = Dirty | Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation. |
| Homeostasis Healing Phase | First stage of wound healing and is the process of the wound being closed by clotting. |
| Inflammatory Healing Phase | is the second stage of wound healing and begins right after the injury when the injured blood vessels leak transudate (made of water, salt, and protein) causing localized swelling. Controls bleeding, prevents infection by removing pathogens, bacteria, and damaged cells from the wound and providing nutrients and enzymes that result in swelling, heat, pain, and redness. |
| Proliferation Healing Phase | is the phase of wound healing is when the wound is rebuilt with new tissue made up of collagen and extracellular matrix. The wound turns pink or red and uneven in texture. Granulation tissue is formed to provide sufficient oxygen and myofibroblasts cause the wound to contract together |
| Maturation Healing Phase | is the remodeling stage where collagen is remodeled and the wound fully closes. Wound is closed and aligned with tension lines producing a scar which makes the skin stronger. Generally begins 21 days after injury |
| Healing by Primary Intention | Tissue is approximated by surgical sutures or tapes with minimal loss of tissue. The wound heals clean, near, with a thin scar. |
| Healing by Secondary Intention | More extensive loss of cells or surface wounds that create large defects. The reparative process is more complication. Granulation tissue grows from the margins to complete the repair. The wounds heal with an ugly scar |
| Healing by Tertiary Intention | Delayed primary wound healing after 4-6 days. This occurs when the process of secondary intention is intentionally interrupted and the wound is mechanically closed. This occurs after granulation tissue has formed, usually |
| Abrasions | Form as a result of rubbing or scrapping of the skin |
| Lacerations | Deeper cuts caused by a sharp object such as a knife |
| Avulsions | Partial or complete tearing away of skin and tissues |
| Post Operative Priorities should be determined using which method | Airway, Breathing, Circulation |
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