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AH EXAM 1
| Term | Definition |
|---|---|
| Hyponatremia | Serum level: <135 mEq/L Signs/symptoms: Poor skin turgor, dry mucosa, headache, decreased saliva, orthostatic BP Neurologic changes: altered mental status, seizures |
| Hyponatremia: Medical treatment: | Treat underlying condition to normalize sodium levels. ADH Receptor Antagonist to block ADH effect at nephron Sodium replacement: Oral, nasogastric, or parenteral routes. Lactated Ringer's solution or isotonic saline. |
| Hyponatremia: Medical treatment: | Avoid increasing serum sodium by >12 mEq/L in 24 hours. Water restriction: For patients with normal/excess fluid volume. Hypertonic sodium solution for severe neurologic symptoms. |
| Hyponatremia: Nursing Management/Interventions: | Identify and monitor at-risk patients. Monitor I&O and daily body weight. Assess for excess water input or insufficient output. Thorough history to identify risk factors. |
| Hyponatremia: Nursing Management/Interventions: | Endurance athletes, older patients, medication use. Monitor for confusion in older patients. Decreased kidney function and fluid excretion. Medications causing sodium loss or water retention. |
| Hypernatremia | Hypernatremia: sodium excess Serum level: >145 mEq/L Signs/symptoms: Thirst, Elevated body temperature, Swollen, dry tongue, Hallucinations, Lethargy, Restlessness, Hyperreflexia, Twitching, Nausea/vomiting, Tachycardia/hypertension |
| Hypernatremia: Medical Treatment: | Gradual lowering of serum sodium levels Ensure adequate PO intake of water Infusion of hypotonic solution (e.g., 0.45% NaCl) or infusion of an isotonic non-saline solution (D5W) |
| Hypernatremia: Medical Treatment: | General rule, serum sodium levels are decreased no faster than 0.5 to 1 mEq/L/h to allow sufficient time for readjustment through diffusion across fluid compartments |
| Hypernatremia:Nursing Management/Interventions: | Assess for abnormal losses of water or low water intake Obtain medical history Observes for any thirst or elevated body temperature Monitored for any neurological issues |
| How rapidly are you anticipating changing sodium levels in 24h?For hypernatremia: | General rule, serum sodium levels are decreased no faster than 0.5 to 1 mEq/L/h to allow sufficient time for readjustment through diffusion across fluid compartments |
| How rapidly are you anticipating changing sodium levels in 24h?For hyponatremia: | Avoid increasing serum sodium by >12 mEq/L in 24 hours. |
| What occurs to the brain when we change sodium too rapidly? | severe neurological damage known as Osmotic Demyelination Syndrome (ODS) - a severe neurological condition characterized by the destruction of the myelin sheath in the brain, including |
| What occurs to the brain when we change sodium too rapidly? | Central Pontine Myelinolysis (CPM) - a rare neurological condition that primarily damages the myelin sheath protecting nerve cells in the pons area of the brainstem |
| What occurs to the brain when we change sodium too rapidly? | Low to high the pons will die High to low the brain will blow (cerebral edema-> cerebral herniation-> brain death) |
| Hypokalemia | <3.5 mEq/L Widespread physiologic derangements. Severe hypokalemia: cardiac/respiratory arrest. Clinical signs: fatigue, anorexia, muscle weakness, polyuria. |
| Hypokalemia | Prolonged hypokalemia: Inability to concentrate urine, glucose intolerance. ECG changes: flat/inverted T waves, depressed ST segments, elevated U wave. |
| Hypokalemia: Medical Treatment: | Preventive measures: increased dietary intake, oral potassium supplements. Foods high in potassium: fruits, vegetables, legumes, whole grains, milk, meat. |
| Hypokalemia: Medical Treatment: | Monitor for worsening hypokalemia or hyperkalemia. Potassium chloride, acetate, or phosphate. IV replacement therapy for severe hypokalemia. |
| How do you administer IV potassium? | *NEVER IVP, ALWAYS IVPB* |
| Hypokalemia: Nursing intervention/management | Monitor at-risk patients for early signs. Fatigue, anorexia, muscle weakness, decreased bowel motility. ECG monitoring for digitalis toxicity. Hypokalemia potentiates digitalis action. |
| Hypokalemia: Nursing intervention/management | Preventive measures: Encourage potassium-rich foods. Educate on laxative/diuretic misuse. Monitor fluid I&O, ECG changes, ABG values. |
| Hyperkalemia | Serum level: >5 mEq/L. Signs/symptoms: Most significant effect: myocardium. Cardiac conduction disturbances. |
| Hyperkalemia | ECG changes: peaked T waves, ST-segment depression, prolonged PR interval. Symptoms: Muscle weakness, tachycardia, arrhythmias. Flaccid paralysis, intestinal colic, irritability, anxiety. |
| Hyperkalemia: Medical treatment | Immediate ECG and serum potassium level. *Repeat serum potassium from a non-infusing vein. Non-acute situations: Restrict dietary potassium and medications. |
| Hyperkalemia: Medical treatment | Cation exchange resins: sodium polystyrene sulfonate, patiromer sorbitex calcium, sodium zirconium cyclosilicate |
| Hyperkalemia: Medical treatment | Emergency pharmacologic therapy: IV calcium gluconate, sodium bicarbonate, insulin with dextrose. Loop diuretics, beta-2 agonists, dialysis. |
| Hyperkalemia: Nursing intervention/management | Monitor at-risk patients (e.g., kidney disease) I&O, muscle weakness, arrhythmias. Apical pulse, paresthesias, GI symptoms. |
| Hyperkalemia: Nursing intervention/management | Preventive measures: Adhere to potassium restriction. Avoid potassium-rich foods: fruits, vegetables, legumes, whole grains. Monitor serum potassium, BUN, creatinine, glucose, ABG values. |
| Hypomagnesemia | Serum level: <1.8 mg/dL. Signs/symptoms: neuromuscular irritability Psychological changes: apathy, depression, agitation, confusion ECG changes: prolonged QRS, depressed ST segment, arrhythmias Concurrent hypokalemia and hypocalcemia |
| Hypomagnesemia: Medical treatment: | Mild deficiency: dietary correction. Magnesium-rich foods: green, leafy vegetables, beans, lentils, almonds Severe deficiency: IV magnesium sulfate Monitor vital signs, urine output Calcium gluconate for concurrent hypocalcemic tetany |
| Hypomagnesemia: Nursing intervention/management | Monitor at-risk patients. Digitalis toxicity, seizure precautions Dysphagia screening Patient education: Magnesium-rich foods: green vegetables, nuts, legumes, bananas, oranges |
| Hypermagnesemia | Serum level: >2.5 mg/dL Signs/symptoms: Acute elevation: CNS and neuromuscular depression Respiratory depression, coma, heart block, cardiac arrest |
| Hypermagnesemia | Platelet clumping, delayed thrombin formation Flushing Hypotension Muscle weakness Drowsiness Decreased DTR |
| Hypermagnesemia: Medical treatment: | Prevent by avoiding magnesium in kidney injury. Discontinue parenteral/oral magnesium salts. Emergency treatment: |
| Hypermagnesemia: Medical treatment: | Ventilatory support, IV calcium gluconate Hemodialysis with magnesium-free dialysate Loop diuretics, sodium chloride, Lactated Ringer's solution |
| What assessment are we doing for patients with elevated magnesium levels? | Vital signs, hypotension, shallow respirations Arrhythmias, bradycardia, heart block |
| Hypophosphatemia | Serum level: <2.5 mg/dL Signs/symptoms: Muscle weakness, bone pain, altered mental status, seizures Medical treatment: Prevention, address the underlying cause, oral phosphate supplements, IV correction if <1 mg/dL |
| Hyperphosphatemia | Serum level: >4.5 mg/dL Signs/symptoms: Tetany, tachycardia, anorexia, n/v, muscle weakness, signs of hypocalcemia, hyperactive reflexes Medical treatment: Reduce phosphate intake, phosphate binders PO with each meal (calcium carbonate, calcium citrate) |
| Hypocalcemia | Serum level: <8.5 mg/dL. Signs/symptoms: Seizures, mental changes, prolonged QT interval, dyspnea. |
| Hypocalcemia: Medical treatment: | Acute symptomatic hypocalcemia: IV calcium salts. Calcium gluconate or calcium chloride. Monitor for digitalis toxicity. |
| Hypocalcemia: Nutritional therapy: | Vitamin D therapy for calcium absorption. Calcium supplements in divided doses. Calcium-rich foods: milk products, green leafy vegetables, canned salmon. |
| Hypercalcemia | Serum level: >10.5 mg/dL. Signs/symptoms: Muscle weakness, constipation, polyuria, dehydration. Severe: thirst, polyuria, muscle weakness, confusion, coma. |
| Hypercalcemia: Medical treatment: | Decrease serum calcium and treat underlying cause. Chemotherapy for malignancy, partial parathyroidectomy |
| Hypercalcemia: Pharmacologic therapy: | IV fluids to dilute calcium, furosemide for diuresis. Calcitonin to reduce bone resorption Bisphosphonates, corticosteroids, mithramycin |
| Understanding of Renin-Angiotensin-Aldosterone system | Trigger: Low perfusion or diminished blood pressure sensed by kidneys Process: Renin release from kidneys Conversion of angiotensinogen to angiotensin I ACE converts angiotensin I to angiotensin II |
| Understanding of Renin-Angiotensin-Aldosterone system | Effects: Vasoconstriction increases arterial blood pressure Aldosterone secretion increases sodium and water reabsorption |
| Fluid Balance: Fluid volume deficit: Patients at risk for developing this: | diabetes insipidus adrenal insufficiency osmotic diuresis Hemorrhage coma |
| Fluid Balance: Fluid volume deficit: Signs/Symptoms: | vomiting diarrhea GI suction sweating Abnormal fluid losses Decreased intake Third-space fluid shifts |
| Fluid Balance: Fluid volume deficit: Medical Management | Planning Correction of Fluid Loss Consider maintenance requirements and other factors (e.g., fever) Oral route preferred if deficit is not severe IV route required for acute or severe fluid losses |
| Fluid Balance: Fluid volume deficit: Medical Management | Isotonic electrolyte crystalloid solutions first-line choice for hypotensive patients (e.g., Lactated Ringer’s, 0.9% sodium chloride) Hypotonic electrolyte solution used once normotensive (e.g., 0.45% sodium chloride) |
| Fluid Balance: Fluid volume deficit: Nursing Management/Interventions | Monitoring and Measuring Fluid I&O Very frequently, sometimes hourly (especially in critical care areas) Vital Signs and Physical Assessment Monitor skin and tongue turgor regularly Evaluate mental function and peripheral perfusion |
| Fluid volume overload: Hypervolemia: Patients at risk for developing this: | Fluid overload or diminished function of homeostatic mechanisms Contributing factors: heart failure, kidney dysfunction, cirrhosis of the liver Excessive sodium intake or administration of sodium-containing fluids |
| Fluid volume overload: Hypervolemia: Signs/Symptoms | Result from expansion of ECF Edema, distended jugular veins, crackles in lungs Edema location varies with patient position (ankles in ambulatory, sacrum in supine) |
| Fluid volume overload: Hypervolemia: Medical Management: | Management directed at causes Discontinue excessive sodium-containing fluids if applicable Symptomatic treatment: diuretics, fluid and sodium restriction |
| Fluid volume overload: Hypervolemia: Medical Management: | Diuretics Reduce sodium and water reabsorption at the nephron Enhance water loss via kidneys Dialysis, if renal function severely impaired |
| Fluid volume overload: Hypervolemia: Nursing Management/Interventions | Monitoring fluid retention Measure I&O at regular intervals Assess patient weight daily for rapid weight gain Monitor breath sounds and degree of edema |
| Fluid volume overload: Hypervolemia: Nursing Management/Interventions | Edema assessment Evaluate pitting edema using a scale (1+ to 4+) Measure extremity circumference with a tape measure |
| Fluids: Hypotonic: | Examples 0.45% Saline solution, D5W Total electrolyte content less than 250 mEq/L |
| Fluids: Hypotonic: When to use: | Replace fluid hypotonic to plasma. Provide free water. Treat hypernatremia and other hyperosmolar conditions. Commonly used: 0.45% Saline solution, D5W Hypotonic solution to provide water and electrolytes for renal excretion of metabolic wastes |
| Fluids: Isotonic: | expand ECF volume Total electrolyte content between 250 and 375 mEq/L |
| Fluids: Isotonic: When to use: | Used to correct dehydration, blood loss, sodium depletion, and replace GI losses |
| Fluids: Hypertonic | 3% NaCl and IV mannitol Total electrolyte content greater than 375 mEq/L |
| Fluids: Hypertonic: When to use: | Used for sodium depletion and acute cerebral edema sodium depletion and acute cerebral edema Often administered into central veins to avoid circulatory overload and dehydration |
| Fluids: Hypertonic: When to use: | Pull water from interstitial and intracellular compartments into the bloodstream. Cause cellular dehydration |
| Is giving IV fluids harmless? What should we monitor for patients receiving IVF? | Causes of fluid overload: Rapid infusion of IV solution, hepatic, cardiac, or kidney disease Increased risk in older patients with cardiac disease |
| Is giving IV fluids harmless? What should we monitor for patients receiving IVF? | Signs and symptoms: Moist crackles, cough, restlessness, distended neck veins, edema, weight gain Dyspnea, rapid shallow respirations Treatment: Decrease IV rate, monitor vital signs, assess breath sounds, high Fowler position |
| Causes of air embolism: | Cannulation of central veins, size and rate of embolus entry Air travels to right ventricle, blocks pulmonary valve |
| air embolism: | Manifestations: Palpitations, dyspnea, coughing, jugular venous distention, wheezing, cyanosis Hypotension, weak rapid pulse, altered mental status, chest, shoulder, low back pain |
| air embolism: | Treatment: Clamp cannula, replace infusion system, Trendelenburg position, assess vital signs, administer oxygen |
| Sources of infection: | Needle reuse, IV access port, medication vial contamination Local involvement to systemic dissemination (sepsis) |
| Sources of infection: | Signs and symptoms: Abrupt temperature elevation, backache, headache, increased pulse and respiratory rate Nausea, vomiting, diarrhea, chills, shaking, general malaise |
| Sources of infection: | Preventive measures: Aseptic techniques, hand hygiene, disinfection of vascular access devices |
| IV therapy can cause local complications such as: | Phlebitis, infiltration, extravasation, thrombophlebitis, hematoma, occlusion, catheter dislodgement |
| How many times can you use a needle? | ONCE |
| What are measures to take to reduce the risk of infection related to IV therapy? | Use aseptic technique, appropriate size cannula, monitor site hourly. Discontinue IV line, apply warm compress, restart IV in another site. Aseptic techniques, hand hygiene, disinfection of vascular access devices |
| Phases of Operative Nursing: Pre-operative: Definition: | Decision to proceed with surgery to transfer to OR bed. |
| Phases of Operative Nursing: Pre-operative: Responsibilities: | Initial preoperative assessment Education appropriate to patient’s needs Involves family in interview. Verifies completion of preoperative diagnostic testing. Confirms understanding of surgeon-specific preoperative therapies. |
| Phases of Operative Nursing: Pre-operative: Responsibilities: | Discusses and reviews advance directive document. Begins discharge planning. Completes preoperative assessment. Assesses for risks for postoperative complications. Reports unexpected findings or deviations from normal. Verifies operative consent. |
| Phases of Operative Nursing: Pre-operative: Responsibilities: | Coordinates patient education and plan of care. Reinforces previous education. Explains perioperative period phases and expectations. Answers patient’s and family’s questions. |
| Phases of Operative Nursing: Pre-operative: Responsibilities: | Identifies patient. Assesses physical and emotional status, baseline pain, and nutritional status. Reviews medical record. Verifies surgical site and marking. |
| Phases of Operative Nursing: Pre-operative: Responsibilities: | Establishes IV line and administers medications if prescribed. Ensures patient’s comfort and provides psychological support. Communicates patient and family’s needs to the health care team. |
| Phases of Operative Nursing: Intra-operative: Definition: | Transfer to OR bed to admission to PACU. |
| Phases of Operative Nursing: Intra-operative: Responsibilities: | Maintain Safety Maintains aseptic, controlled environment. Manages human resources, equipment, and supplies. Transfers patient to OR bed or table. Positions patient for functional alignment and surgical site exposure. |
| Phases of Operative Nursing: Intra-operative: Responsibilities: | Applies grounding device. Ensures correct sponge, needle, and instrument counts. Completes intraoperative documentation. |
| Phases of Operative Nursing: Intra-operative: Responsibilities: | Physiologic monitoring Communicates fluid instillation and blood loss. Distinguishes normal from abnormal cardiovascular data. Reports changes in vital signs. Institutes measures to promote normothermia. |
| Phases of Operative Nursing: Intra-operative: Responsibilities: | Psychologic support Provides emotional support to patient. Stands near or touches patient during procedures and induction. Continues to assess emotional status. Notifies family or significant others of updates throughout the procedure. |
| Phases of Operative Nursing: Post-operative: Definition: | Admission to PACU to follow-up evaluation. |
| Phases of Operative Nursing: Post-operative: Responsibilities: | Identifies patient by name. States type of surgery performed. Identifies type and amounts of anesthetic and analgesic agents used. |
| Phases of Operative Nursing: Post-operative: Responsibilities: | Reports vital signs and response to surgery and anesthesia. Describes intraoperative factors and physical limitations. Communicates necessary equipment needs and presence of family. |
| Classifications of Surgery | Diagnostic procedures (e.g., biopsy, exploratory laparotomy) Curative procedures (e.g., tumor excision, appendectomy) Repair procedures (e.g., multiple wound repair) |
| Classifications of Surgery: Emergent: | Immediate attention required; life-threatening conditions Examples: severe bleeding, bladder obstruction, extensive burns |
| Classifications of Surgery: Urgent: | Prompt attention within 24 to 30 hours Examples: closed fractures, infected wound exploration |
| Classifications of Surgery: Required: | Surgery needed within weeks or months Examples: prostatic hyperplasia, thyroid disorders |
| Classifications of Surgery: Elective: | Surgery should be performed but not catastrophic if delayed Examples: repair of scars, simple hernia |
| Classifications of Surgery: Optional: | Patient's personal preference Example: cosmetic surgery |
| Types of Procedures: | Reconstructive or cosmetic (e.g., mammoplasty, facelift) Palliative (e.g., tumor debulking, gallbladder removal) Rehabilitative (e.g., total joint replacement) |
| Considerations during Preoperative period | Safety measures Developed by The Joint Commission and CMS Aim to prevent surgical complications like VTE, SSIs, and wrong-site surgery |
| Considerations during Preoperative period | Medication reconciliation Verify home medications with the patient Confirm which medications were discontinued and when Critical component of the patient interview |
| Patients with Disabilities: Communication needs: | Sign language interpreter or alternative communication for deaf/hard of hearing Identify and communicate needs in preoperative evaluation |
| Patients with Disabilities: Assistive devices: | Include hearing aids, eyeglasses, braces, prostheses Ensure security and availability perioperatively |
| Pre-operative Assessment: Respiratory: | Breathing exercises and incentive spirometer use Decrease pulmonary complications Assess respiratory health Postpone surgery if respiratory infection is present |
| Pre-operative Assessment: Respiratory: | Reduce postoperative complications by assessing for underlying respiratory diseases Assess tobacco use during preoperative assessment and encourage smoking cessation |
| Pre-operative Assessment: Cardiovascular: | Interdisciplinary Team Approach for Optimization Preoperative Cardiac Assessment Identify cardiac comorbidities Complete diagnostic testing as needed (e,g., EKG, echo) |
| Pre-operative Assessment: Nutritional: | Importance of optimal nutrition to promote healing and resist infections Identifies factors affecting surgical course (e.g., obesity, malnutrition) Correct nutritional deficiencies before surgery |
| Pre-operative Assessment: Nutritional: | Confirm NPO status preoperatively Prevent dehydration and electrolyte imbalances |
| Pre-operative Assessment: Metabolic: | Importance of optimal liver and kidney function Metabolize and eliminate medications, anesthetics, and toxins Assess liver function with various tests |
| Pre-operative Assessment: Metabolic: | Kidney Function Assessment Contraindications for surgery with acute kidney issues Exceptions for lifesaving measures or improving urinary function |
| Pre-operative Assessment:Endocrine: | Endocrine Dysfunction and Surgery Overproduction or underproduction of hormones Risk of adrenal insufficiency with corticosteroid use |
| Pre-operative Assessment:Endocrine: | Thyroid Disorders Assess for hyperthyroidism or hypothyroidism Monitor for thyrotoxicosis or respiratory failure 2/2 hypothyroidism |
| Pre-operative Assessment:Endocrine: | Diabetes Management Risk of hypoglycemia and hyperglycemia Importance of strict glycemic control |
| Pre-operative Assessment:Immune: | Preoperative Infection and Allergy Assessment Routine tests: WBC count and urinalysis Postpone surgery if infection or elevated temperature present |
| Pre-operative Assessment:Immune: | Allergy Documentation Identify and document sensitivities to medications and other substances Use latex allergy screening questionnaire |
| Surgical Complications: Common complications & their preventative measures: Venous Thromboembolism (VTE): | Prevention: pharmacologic prophylaxis, external pneumatic compression, antiembolism stockings Risk factors: history of thrombosis, malignancy, trauma, obesity, indwelling venous catheters, hormone use |
| Surgical Complications: Common complications & their preventative measures: Venous Thromboembolism (VTE): | Symptoms: pain or cramp in calf, tachypnea, chest pain, hemoptysis, shortness of breath, sense of impending doom |
| Surgical Complications: Common complications & their preventative measures: Hematoma: | Concealed bleeding, clot formation, delayed healing Treatment: evacuation of clot, secondary closure |
| Surgical Complications: Common complications & their preventative measures: Infection (Wound Sepsis): | Risk factors: type of wound, patient-related factors, surgical procedure-related factors Preventive efforts: antiseptic skin preparation, hair removal, antimicrobial stewardship, optimal OR care |
| Surgical Complications: Common complications & their preventative measures: Infection (Wound Sepsis): | Postoperative care: assessing wound, preventing contamination, enhancing healing |
| Serious Surgical Complications:Dehiscence: | Dehiscence (disruption of incision), evisceration (protrusion of wound contents) |
| Serious Surgical Complications:Dehiscence: | Causes: Sutures giving way, infection, distention, strenuous cough, age, anemia, poor nutrition, obesity, malignancy, diabetes, corticosteroids |
| Serious Surgical Complications:Dehiscence: | Signs: Gradual or sudden separation of wound edges, protrusion of intestines, pain, vomiting Management: Low Fowler position, sterile dressings moistened with saline, notify surgeon |
| Serious Surgical Complications: When should education on these begin: | Begins before surgery, includes postoperative wound care, identification and prevention of complications |
| Intra-Operative Nursing: Who makes up the surgical team? | Patient Anesthesia Surgeon Nurses Surgical Tech RNFA/Certified surgical technologist |
| Intra-Operative Nursing: What is the nurse’s role?: | Collaborates with surgical team Manages OR environment Monitors patient safety and health Verifies consent and coordinates team Ensures patient safety and well-being |
| Intra-Operative Nursing: Adverse effects of surgery and anesthesia: | Agitation or disorientation Allergic reactions Anesthesia awareness Bleeding Cardiac arrhythmia Central nervous system agitation Drug toxicity and human error |
| Intra-Operative Nursing: Adverse effects of surgery and anesthesia: | Electrical shock or burns Hypotension and hypothermia Hypoxemia or hypercarbia Infection Laryngeal and oral trauma Laser burns Malignant hyperthermia Myocardial depression and bradycardia |
| Intra-Operative Nursing: Adverse effects of surgery and anesthesia: | Nerve damage and skin breakdown Oversedation or undersedation Retained foreign body Thrombosis |
| Intra-Operative Nursing: Types of Anesthesia (what is is, how it is administered, potential complications to monitor for) | General anesthesia (inhalation, IV) Regional anesthesia (epidural, spinal, local conduction blocks) Moderate sedation (monitored anesthesia care [MAC]) Local anesthesia |
| Intra-Operative Nursing: Types of Anesthesia (what is is, how it is administered, potential complications to monitor for) | IV line insertion and sedating agent administration Loss of consciousness and possible intubation Combination of anesthetic agents used |
| Hypoxia | Brain damage from hypoxia occurs within minutes. |
| Anaphylaxis | Asphyxia can be caused by foreign bodies, vocal cord spasm, tongue relaxation, or aspiration. |
| Malignant Hyperthermia: Medical Management: | Treatment goals include decreasing metabolism, reversing acidosis, correcting arrhythmias, decreasing body temperature, providing oxygen and nutrition, and correcting electrolyte imbalance. Dantrolene use has lowered mortality rates to 10%. |
| Malignant Hyperthermia: Medical Management: | Malignant Hyperthermia Association of the United States (MHAUS) provides a treatment protocol. Anesthesia and surgery should be postponed. |
| Malignant Hyperthermia: Medical Management: | Alternative anesthetics can also trigger malignant hyperthermia. Usually manifests 1020 minutes after induction but can occur within 24 hours post-surgery. |
| Malignant Hyperthermia: Nursing Management: | Nurses must identify at-risk patients, recognize signs and symptoms, have appropriate medication and equipment available, and follow protocol. Preparation and early intervention are crucial for patient safety. |
| Post-operative Nursing: Goal of PACU: | to ensure patient safety and recovery from anesthesia. |
| Post-operative Nursing: Who is the primary provider in the PACU?: | anesthesia providers Transfer responsibility lies with the anesthesiologist or CRNA and OR team. |
| Post-operative Nursing: What is nursing’s top priority in the PACU?: | The goal is to ensure patient safety and recovery from anesthesia. Maintain ventilation to prevent hypoxemia and hypercapnia. Assess respiratory rate, depth, ease, oxygen saturation, and breath sounds. |
| Post-operative Nursing: What complications are you being mindful of when assessing patient’s in the PACU?: | Hypotension and shock Hemorrhage/ bleeding Hypertension/ elevated temperature arrhythmias |
| Post-operative Nursing: What complications are you being mindful of when assessing patient’s in the PACU?: | Hypopharyngeal obstruction: Occurs when the lower jaw and tongue fall backward. Signs: Choking, noisy and irregular respirations, decreased oxygen saturation, cyanosis. |
| Post-operative Nursing: What complications are you being mindful of when assessing patient’s in the PACU?: | Frequent, basic assessments include: Airway, level of consciousness, cardiac, respiratory, wound, and pain. Additional assessments based on comorbidities and procedure type. Peripheral pulses, hemodynamics, surgical drain placements. |
| Post-operative Nursing: How do we determine if a patient can leave the PACU?: | Stable blood pressure, adequate respiratory function, adequate oxygen saturation. Aldrete score used to determine readiness for transfer. Score between 7 and 10 before discharge. |
| Post-operative Nursing: How do we determine if a patient can leave the PACU?: | Regular assessment and scoring: Scores lower than preestablished level require evaluation by anesthesia provider or surgeon. |
| Surgical complications: | Pulmonary infection/hypoxia Venous thromboembolism (VTE) Hematoma or hemorrhage Infection Wound dehiscence or evisceration |
| Types of Surgical Drains: | Penrose, Jackson-Pratt, Hemovac |
| Pain Management: Definition of pain: | Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is subjective: "… whatever the experiencing person says it is, existing whenever he says it does" (McCaffery, 1968). |
| Pain Management: Definition of pain: | Self-report of pain is the standard for pain assessment. |
| Pain Management: How do we score pain? non-verbal patients: | rbal: Observational tools can help when patients cannot self-report pain. Assign scores by observing behaviors associated with pain. |
| Pain Management: How do we score pain? non-verbal patients: | Behaviors can indicate pain presence, but absence does not indicate no pain. We assume pain until behavior tells us otherwise |
| Pain Management: How do we talk about pain with patients: | Location(s) of Pain Ask the patient to state or point to the area(s) of pain. Using a body diagram can be helpful. |
| Pain Management: How do we talk about pain with patients: | Intensity: Ask the patient to rate pain severity using a reliable tool. Educate patients and families on using a pain rating scale. Pain intensity ratings are valid only if self-reported. Tools measure only pain intensity, not total scores. |
| Pain Management: How do we talk about pain with patients:Quality, Onset, and Duration of Pain: | Quality: Ask the patient to describe how the pain feels (e.g., sharp, shooting, burning). Onset and Duration: Ask when the pain started and if it is constant or intermittent. |
| Pain Management: How do we talk about pain with patients:Quality, Onset, and Duration of Pain: | Aggravating and Relieving Factors: Ask what makes the pain worse and what makes it better. |
| Pain Management:Effect of Pain on Function and Quality of Life: | Assess the effect of pain on the patient's ability to perform activities. Particularly important for patients with persistent pain. Ask what activities they could do before the pain began. |
| Pain Management:Effect of Pain on Function and Quality of Life: | Comfort–Function Goal: Identify short-term functional goals for acute pain patients. For chronic pain, identify unique functional or quality-of-life goals. Measure success by progress toward meeting these goals. |
| Types of pain | Pain categorized by duration: acute or chronic (persistent) Acute pain: tissue damage from surgery, trauma, burn, or venipuncture. Chronic pain: cancer or noncancer origin, can persist throughout life. |
| Types of pain | Pain categorized by inferred pathology Nociceptive pain: arises from damage to non-neural tissue, normal pain transmission. Neuropathic pain: caused by lesion or disease of the somatosensory nervous system. |
| Medication options: Name/route/class/when to reassess pain: | Opioids: Morphine, fentanyl, hydrocodone, hydromorphone, oxycodone, oxymorphone Non-opioid analgesics: Non-steroidal anti-inflammatory agents (NSAIDs) (e.g., ibuprofen) COX-2 inhibitors (e.g., celecoxib), Acetaminophen |
| Medication options: Name/route/class/when to reassess pain: | Local anesthetics: Lidocaine patch Anti-convulsant medications: Pregabalin Anti-depressants: Tricyclic antidepressants (TCAs) (e.g., amitriptyline) Serotonin and norepinephrine reuptake inhibitors (SNRIs) (e.g. duloxetine) |
| Medication options: Name/route/class/when to reassess pain: | Dissociative anesthetic: Ketamine Toradol: IV: can’t be given to kidney pts or if on another NSAID |
| Reassess pain: | Reassess and document pain regularly to evaluate treatment effectiveness. Minimum reassessment with each new pain report and before/after analgesic administration. |
| Frequency of reassessment depends on patient stability and medication peak effect. | 15 to 30 minutes post parenteral administration. 1 to 2 hours post oral administration. In PACU, reassessment may be as often as every 10 minutes during IV opioid titration. |
| Pressure Injuries: Stage l: | Intact skin Non-blanchable erythema (No purple/maroon skin) Changes in sensation, temperature, firmness may proceed visual changes |
| Pressure Injuries: Stage ll: | Partial thickness skin loss with exposed dermis Wound bed is: Viable Pink or red Moist May present as serum-filled blister No adipose or deep tissues visible No granulation tissue, slough, eschar |
| Pressure Injuries: Stage lll: | Full thickness skin loss Adipose visible Granulation tissue and epibole (rolled edges) present Fascia, muscle, tendon, ligament, cartilage, bone are not exposed Undermining and tunneling may be present |
| Pressure Injuries: Stage lV: | Full thickness skin and tissue loss Exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone noted Epibole, undermining, tunnelling often present |
| DTI? | Intact or non-intact skin w/ localized area of Persistent, non-blanching red/maroon/purple discoloration Epidermal separation w/ dark wound bed or blood-filled blister |
| DTI? | Result of intense or prolonged pressure & shear forces DO NOT classify a wound as a DTPI if there is necrotic tissue |
| Medical management of skin breakdown: | Includes prescribed and OTC pharmacologic therapies |
| Medical management of skin breakdown: Topical medications: | Topical medications: Prepared in various vehicles like lotions, creams, gels, ointments, sprays, or patches High concentrations can be applied directly to the affected site. Some medications can produce systemic effects. |
| Medical management of skin breakdown: Patient education: | Apply medication gently but thoroughly. Cover medication with a dressing if necessary to protect clothing. Report any allergic reactions immediately. |
| Medical management of skin breakdown: Nursing Management: | Begins with a focused dermatologic health history and physical examination |
| Medical management of skin breakdown: Nursing Management: Major goals for the patient: | Maintenance of skin integrity Relief of discomfort Promotion of restful sleep Self-acceptance Knowledge about skin care Avoidance of complications |
| Medical management of skin breakdown: Nursing Management: Patient education for self-care: | Cleanse the affected area and pat it dry. Apply medication to the lesion while the skin is moist. |
| Medical management of skin breakdown: Nursing Management: Patient education for self-care: | Use occlusion if prescribed to enhance medication absorption. Remove dressings containing corticosteroids for 12 hours every 24 hours to prevent adverse events. |
| Causes of Pressure Injuries: | Localized area of necrotic soft tissue due to pressure >32 mm Hg Critically ill patients have lower capillary closure pressure. |
| Prevention of Pressure Injuries: | Relief of pressure Improved mobility Maintenance of skin integrity Improved sensory perception and tissue perfusion Improved nutritional status Minimized friction and shear forces |
| Prevention of Pressure Injuries: | Dry surfaces in contact with skin Healing of pressure injury, if present Frequent changes to relieve and redistribute pressure |
| Prevention of Pressure Injuries: | Educate family on positioning and turning at home Ambulate patients whenever possible Turning and exercise schedules essential for at risk patients |
| Atelectasis: Patients at risk for developing this: | Nonobstructive: Results from reduced ventilation. Obstructive: Caused by blockage impeding air passage. |
| Atelectasis: Signs/Symptoms: | Increasing dyspnea, cough, and sputum production. Increased work of breathing and hypoxemia. |
| Atelectasis: Signs/Symptoms: | Decreased breath sounds and crackles over affected area. Chest x-ray: Patchy infiltrates or consolidated areas. Pulse oximetry: Low hemoglobin saturation (<90%). |
| Atelectasis: Medical Management: | Treatment Goals Improve ventilation and remove secretions. Firstline measures: Frequent turning, early ambulation, lung volume expansion, coughing. Use of positive expiratory pressure (PEP) devices. |
| Atelectasis: Medical Management: | Advanced treatments: Positive end-expiratory pressure (PEEP), continuous positive airway pressure (CPAP), bronchoscopy. Severe: Endotracheal intubation & mechanical ventilation. Chronic: Remove airway obstruction or lung tissue compression. |
| Atelectasis: Medical Management: Techniques for secretion management: | Directed cough and suctioning. Aerosol nebulizer treatments followed by chest physiotherapy (CPT) and postural drainage. |
| Atelectasis: Medical Management: Techniques for secretion management: | Use of pressurized metered-dose inhaler (pMDI) for bronchodilators. Bronchoscopy for secretion removal and airway patency maintenance. |
| Atelectasis: Nursing Management/Interventions: | Frequent turning and early mobilization. Strategies to expand lungs and manage secretions. |
| Atelectasis: Nursing Management/Interventions: | Voluntary deep breathing maneuvers every 2 hours. Use of incentive spirometry for visual feedback and lung expansion. Volume type: Set tidal volume, deep breath through mouthpiece. Flow type: Movable balls indicate air volume and flow. |
| Pneumonia: Patients at risk for developing this: | adults 65 and older, children under age 2, and individuals with weakened immune systems. ( COPD, ASTHMA, EMPHYSEMA) |
| Pneumonia: Signs/Symptoms: | Fever Chills Cough Sputum production Fatigue Loss of appetite Dyspnea Tachypnea |
| Pneumonia: Medical Management: | Antibiotic therapy Supplemental oxygen therapy Hydration & nutrition |
| Pneumonia: Nursing Management/Interventions: | Thorough assessment Focus on respiratory VAP bundles (see Chart 19-4) Encourage and educate on vaccinations (Pneumococcal conjugate vaccines [PCV 15 or PCV20]) Hand hygiene |
| Pneumonia: Nursing Management/Interventions: | Coughing and Deep breathing exercises Incentive spirometry Turning and repositioning Chest PT Supplemental oxygen therapy Promoting adequate nutrition and hydration |
| Pneumonia: Complications: | Shock Respiratory failure Supportive oxygen therapy NC > intubation Pleural effusions Atelectasis Delirium |
| COPD: TYPES: | Generic term that describes all chronic obstructive lung problems Emphysema Chronic Bronchitis |
| COPD: | Progressive, unremitting, and irreversible disease that has symptom management options to slow progression Limitation in airflow that is linked to abnormal inflammation and results in chronic airway changes and narrowing |
| COPD: Medical Management: | Supplemental oxygen Medications to manage exacerbations Surgical Intervention Bullectomy Lung reduction Lung transplant |
| COPD: Nursing Management/Interventions: | History and Physical exam Educate patients on disease, diagnosis, prognosis, and treatment Assess current symptoms Help achieve airway clearance |
| COPD: Complications: | Respiratory insufficiency and failure Pneumonia Chronic atelectasis Pneumothorax Cor pulmonale |
| EMPHYSEMA: | Irreversible enlargement of the air spaces beyond terminal bronchioles, most notably in the alveoli Destruction of the alveolar walls Obstruction of airflow |
| EMPHYSEMA: | Chronic smoking most often implicated, though can be genetic Early or mild: primary source of obstruction is development of inflammation in the small airways distal to the bronchioles |
| EMPHYSEMA: | Moderate-to-severe: loss of elastic recoil in the alveoli occurs and becomes the primary mechanism of airflow obstruction Arteries and arterioles become thick and fibrotic leading to further capillary destruction |
| EMPHYSEMA: Medical Management: | Focus is on symptom management and preventing disease progression Maintain optimal lung function in order to allow the individual to perform the desired activities of daily life Smoking cessation |
| EMPHYSEMA: Pharmacologic therapy: | Bronchodilators Steroids Mucolytic agents |
| EMPHYSEMA: Surgical options: | Lung volume reduction Lung transplant |
| CHRONIC BRONCHITIS: | Persistent, productive cough lasting ≥3 months for ≥2 consecutive years Most commonly a result of smoking or exposure to environmental pollutants |
| CHRONIC BRONCHITIS: Result of: | Chronic inflammation and edema of airways Hyperplasia of bronchial mucous glands and smooth muscles Destruction of cilia Squamous cell metaplasia Bronchial wall thickening, fibrosis development |
| CHRONIC BRONCHITIS: Medical Management: | Focusing on symptom management and prevention of disease progression Smoking cessation Pulmonary rehabilitation |
| CHRONIC BRONCHITIS: Pharmacologic therapy: | Bronchodilators Steroidal anti-inflammatory drugs Mucolytic agents Supplemental oxygen |
| ASTHMA: Signs/Symptoms: | Wheezing In the lung fields Squeaky, high pitched Tachypnea Dyspnea and coughing Chest tightness Excessive sputum production Anxiety Ominous sign: Silent chest |
| ASTHMA: Medical Management: | Identify triggers Dust, mites, pollen, mold |
| ASTHMA: Nursing Management/Interventions: | Monitor lung function Control environmental triggers Pharmacologic therapy Rescue Inhalers: Albuterol Short Acting Beta2-Adrenergic Agonists (SABA) Long Acting Beta2-Adrenergic Agonists (LABA) Antihistamines Leukotriene modifiers Glucocorticoids |
| ANAPHYLAXIS: Patients at risk for developing this: | individuals who have a history of previous severe allergic reactions, poorly controlled asthma, or underlying cardiovascular and lung diseases |
| ANAPHYLAXIS: Signs/Symptoms: | Wheezing, airway obstruction Angioedema Flushing Pruritus, urticaria Respiratory and circulatory failure |
| ANAPHYLAXIS: Medical Management: | Removal of causative agent IV access IM epinephrine IV Diphenhydramine +/- famotidine Nebulized SABA Steroids CPR +/- endotracheal intubation IV Fluids (for hypotension) |
| ANAPHYLAXIS: Nursing Management/Interventions: | Prevention (if possible) Early recognition Head-to-toe assessment Vital signs Assess for allergies Identify patients appropriately |
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