ADN 140 Test 1 material PDF

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Prof. Brandi Miller...

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ADN 140: Test 1: Surgery & Diabetes (intro)  - Withdrawal: feel like you want to die because you stopped the medication abruptly. Feel anxious, irritable, chills or hot flashes, joint pain…..reverse of anti-SLUD ○ Interactions: interacts with any drug that does that same thing…..alcohol,bentos,barbiturates, MAOIs ● Patient Controlled Analgesia (PCA) ○ Medications → typically opioids: morphine or hydromorphone ○ Administration→ patient has to push the button. ■ Basal Rate (base rate) is ordered (1mg/hr) ■ Bolus that can be given (0.25 mg) Classifications of Surgeries ● Purpose ○ Reconstructive → skin graft or knee replacement ○ Incidental → wasn’t the reason that you did the surgery, but you get it fixed while you’re in there ■ Get your gallbladder out & find out you have a mass so you get that removed too ■ Woman gets a c-section and also gets tubes tied ○ Ablative → to cut away ■ Removing gallbladder ■ Uterine ablation ○ Palliative → to relieve unpleasant sx or pain. Not curative but relieves pain or makes you feel better ■ Peg tube placed for esophageal cancer ■ Patients with metastatic cancer in abdomen get a partial bowel resection to relieve abdominal pain ○ Transplant → take old organ out and put a new one in ■ From a living or deceased patient ○ Diagnostic → trying to find out what is causing the issue ■ Exploratory lap ■ Breast biopsy ■ Colonoscopy ■ Endoscopy → to find GI bleed ○ Constructive → building something that wasn’t ever there ■ Cleft lip/palate ○ Cosmetic → alter your appearance (burns or plastic surgery) ■ Liposuction, face lift, stomach lift ■ Removing extra skin from weight loss 1

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● Degree of Urgency ○ Elective → chosen to do / planned; not so critical that we can’t plan ahead for it ■ Bariatric ■ Knee / Hip replacements ■ Tubes tied if it isn’t incidental ○ Urgent → needs to be done relatively immediately, but not going to rush you into surgery ■ Stable appendicitis ○ Emergency → need to get IMMEDIATE surgery. Life or death ■ Trauma from car accident ■ Aortic dissection ■ Aneurysm bursting ● Degree of Risk ○ Minor → local anesthesia or shorter time ■ Cataracts ■ Mole removal ■ Wisdom teeth removal ○ Major → general anesthesia ■ Heart surgery ■ Transplant ■ Appendectomy ■ Tonsil removal ● Setting ○ Inpatient → patients are in the hospital and stay overnight. They don’t go home the same day ○ Ambulatory → outpatient (this can still be done in the hospital, but you go home the same day) Surgical Risk Factors ● General Health → careful review of overall health:  if patient is in poor health state surgery may be cancelled or delayed & if patient is high risk for infection then antibiotics are given prophylactically ● Medications → anticoagulants(increase risk of bleeding), insulin, diuretics(fluid/electrolyte imbalance), steroids(risk of bleeding, infection, delay wound healing & immune response), narcotics(interfere with anesthesia), herbals & over the counter (affect patients reaction to the stress of surgery, may potentiate action of anesthetic agents or increase risk for bleeding), antihypertensives , tranquilizers (risk for resp. depression)  ental & Cognitive Status → schizophrenia, dementia, developmental delays can ● M compromise the ability for the patient to interpret & understand medical information. May not be able to sign informed consent. 2

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● Nutrition → malnutrition / obesity. Protein & Vit K contribute to poor wound healing, respiratory depression, sedation, clotting disorders ● Blood Coagulation Disorders → bleeding, hemorrhage, blood clots, and shock. Must check PTT, platelets, RBCs, hemoglobin, & hematocrit ● Respiratory Disorders → COPD & pneumonia …..anesthesia can cause respiratory depression ● Renal Disorders → contribute to fluid & electrolyte imbalances. ○ BP abnormalities, acid/base imbalances, altered excretion & metabolism of drugs ● Liver Disease → interferes with protein synthesis, metabolism, coagulation, & glucose homeostasis ● Diabetes Mellitus → can increase the risk of delayed wound healing ● Use of illicit drugs → higher risk of adverse drug interactions. Wound healing decreases with nicotine (vasoconstriction). Drug users need more anesthesia and more pain medications because of their tolerance ● Family History → malignant hyperthermia (triggered by muscle relaxant & inhaled anesthetics) ● Previous Surgery → possible post op complications or problems with anesthesia Phases of Surgery ● Preoperative Care ○ Nursing Assessment ■ HTT assessment ■ Respiratory assessment ■ H&P ■ Review PreOp test results → make sure they’re all completed ■ LOC ■ Vitals ■ Allergies ■ Medications ■ Medical & Surgical Hx ■ Tobacco, alcohol, or illicit drug use ■ Cultural considerations ■ Understanding of surgery ■ Pre Existing conditions ■ Ask them how they’re feeling ■ Ask how long they have been NPO for to prevent aspiration ○ Nursing Interventions ■ Teaching ● About anxiety ● PreOp testing 3

● Bathing instructions ● Pain Management Plan → pain goal of zero is unrealistic ● Wound care or drain care ● Incentive spirometer ● Cough and deep breathing ■ Informed consent ■ Patient preparation / checklist ■ Help them understand the procedure ○ PreOp Diagnostic Tests ■ CBC → detect hemorrhage, dietary deficiencies, anemia, hydration status, coagulation ability, hemoglobin, & infection ■ Electrolytes → ● Mg: 1.5-2.5 ● Phosphate: 2.5-4.5 ● K → 3.5-5 ● Ca → 1.5-5 ● Na → 135-145 ■ BUN & creatinine → renal function ● Creatinine : 0.6-1.2 ● BUN: 7-25 ■ Pulmonary Function Test → detect pulmonary deficiencies ■ Chest X-Ray → obtain information on the heart, lungs, bone structure, & large blood vessels in the chest ■ Blood Glucose → evaluate diabetics (surgery increases BG) ● 25 pregnant ○ Informed Consent ■ Surgeons Role ● Obtained prior to sedation 4

● Provide information to the patient ● Procedure & site ● Benefits ,risks, complications, alternatives ● Photographs, videos, observers ● Anesthesia ■ Nurse’s Role ● Verify correct patient identity ● Witness patient voluntary signature ■ Who Can’t give Consent? ● Minors → parent or guardian ● Dementia / altered mental state/ delayed → patients who cannot fully understand or comprehend surgery ○ Guardian or DPOA can sign  ○ Preoperative Checklist ■ Client teaching completed ■ Consent signed ■ NPO ■ In gown ■ Allergy & ID bands on ■ No jewelry or bands taped ■ Voiding prior to transfer ■ Pre Op meds ■ Side rails up after Pre Op ■ Contact lens out ■ Dentures or bridges out ■ Nail polish removed ■ Vitals within 4 hours of surgery or 30 minutes after PreOp ■ PreOp lab work on chart ■ Abnormal lab values ■ Skin prep ■ Hx of → aspirin, antidepressant, steroid, NSAIDs ● Intraoperative Phase ○ Intraoperative Surgical Team Roles ■ Respond to the client's blood pressure or oxygen saturation drops during  nesthesiologist surgery → a ■ Position the patient on the OR table and pad vulnerable places → c irculating nurse ■ Insert foley if needed → c irculating nurse ■ Set up sterile field → s crub 5

■ Add sterile supplies to the sterile field during surgery → c irculating nurse ■ Maintain count of sponges, sharps, and instruments → s crub & circulating nurse ■ Perform surgical scrub → s urgeon scrub & assistant ■ Document what occurs in the OR → c irculating nurse ■ Communicate information about clients condition to family during surgery → circulating nurse ● Intraoperative Nurse ○ Count sponges, sharps, and instruments ○ Call timeout ○ Prep, position, and monitor patient during surgery ○ Unsterile person in the room ○ Charting ○ Monitor sterile field ○ Nursing Assessment ■ Continuous vitals : always watching ■ Positioning ■ Seeing the marking of surgical site before surgery ■ Monitoring sterile field ■ Monitoring blood loss ■ Monitoring thermal regulation : temp probe in foley or thermometer that sticks to forehead : normothermia = better outcomes ■ S/Sx of adverse reactions ○ Nursing Interventions ■ Document ■ Position or reposition ■ Update family ■ Counting instruments ■ Assisting anesthesiologist ■ Surgical safety checklist ■ Managing the OR ■ Receives specimens from sterile field and send to lab ○ Safety in the OR ■ Culture of safety ■ Aseptic Practices : “without infection” …… preventing surgical site infections, prepping the patients skin to reduce # organisms, wearing surgical scrubs, shoe covers, hair net, goggles, maintaining sterile field ■ Patient positioning: ask if they mobility issues or problems lifting/bending arms/legs/hips...knowing pt limitations so no injury is caused in OR 6

■ Preventing retained surgical items ■ Preventing client injury ■ Wound management ■ Anesthesia/medication safety ■ Physical/chemical hazards ○ Universal Protocol ■ Three steps : prevent wrong person, procedure, and site surgeries ● Preoperative verification process : making sure the right equipment is there, all paper work and tests are completed, making sure right patient ● Marking the operative site : done with patient and surgeon ● Time-out immediately before starting procedure ○ Anesthesia: sensation, movement, and consciousness ■ General: feels no pain, paralyzed, not conscious. No sense of time. Cannot maintain own airway & has to be intubated ■ Conscious (moderate): awake, but cannot feel bad. Still in control of muscles & can maintain airway & follow commands. Typically don’t remember anything afterwards. ■ Regional: nerve block, spinal, epidural ■ Local: lidocaine injected at site that you need numbing ● Malignant Hyperthermia ○ Increase in endtidal CO2 (1st sx) ○ Temp goes up ○ Tachycardia ■ Treat by stopping anesthesia & give dandtrolene ■ Can happen during and after surgery ○ Nurse is monitoring a client who is receiving conscious sedation. Which outcome for conscious sedation is expected?  ■ Decreases LOC, yet able to respond to verbal commands ○ The nurse is preparing the clients skin prior to surgery. What is the purpose of the preoperative patient skin prep? ■ Reduce the number of microorganisms at the surgical site ○ What is the most critical component when the nurse is preparing to transfer to the client from the stretcher to the operating table? ■ A sufficiency number of personnel ● Post-Operative ○ Post-Op Nursing Assessments ■ Immediate ● Respiratory: count RR, O2 stat., listen to breath sounds and note quality of breathing 7

● Cardiovascular: vitals, listening to heart sounds, cap refill ● Neuro: orientation (ask name, what they had done, where they are,etc), grips & foot pushes ● Dressings/Incisions ■ Ongoing ● I/O ● Potency of lines & drains ● Correct infusion rates ● Vitals ● Incision & Dressing : look under the patient for pooling of blood ● Respiratory status ● Neuro ● Pain ● Labs ○ A client has arrived post-op unit. What action by the circulating nurse takes priority? ■ Participating in hand off report ○ The post anesthesia care unit charge nurse notes vital signs on four postoperative clients. Which client does the nurse assess first? ■ Client with RR of 6 breath/min ○ A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and manage a drain at home. What instruction that the nurse teaches is most important? ■ Wash your hands before touching the dressing or drain ● Pain Management ○ Non Pharm ■ Deep breathing ■ Distraction ■ Music ■ Heat ■ Cold ○ Pharmacological ■ Non-Opioid ● Acetaminophen ● NSAIDs (ibuprofen) ■ Adjuvant Meds

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● Antidepressant or anti-convulsant added to another pain med to make them work better ● Steroids ■ Opioids ● Opioids Analgesics : anti-SLUD (salivation (dry mouth) ,lacrimation(no tears) , urination(can’t urinate), defecation (constipation) ○ MOA: ■ Agonist: bind to opiate receptors and cause pain relief (analgesia) ■ Agonist-Antagonist: given alone binds to receptors and relieves pain. If given with a larger drug (morphine) binds to the site knocks the morphine off those receptors (pain relief will get worse and then just gives milder pain relief) ■ Antagonist: binds to opiate/pain receptors and prevents an agonist from binding there so it reverses it (takes pain relief (analgesia) away) ○ Equianalgesia: different narcotics have different potencies ○ Opioid Tolerance & Physical Dependence: your body gets used to having pain receptors blocked, so naturally your body needs/wants the medication ○ Psychological Dependence: addiction. Using it for euphoria instead of how the med was intended to be used ○ Overdose: your body has too much medication (decreased RR is first sx) ■  ■ Cap on how much can be given within an hour to prevent overdose (2mg/hr) ○ Effects → patient cant control it, so if they don’t need the meds then they won’t push the button. ■ This helps with better pain control and less opioid use with the patient in control of controlling their own pain. ○ PCA by Proxy → ONLY the patient should be pushing the button. Family members can NOT press for the patient & staff cannot press it either. Patient is in CONTROL. ● Postoperative Complications ○ Airway Obstruction → manual opening of airway, suctioning, ambu bag ○ Hemorrhage / Shock → controlling bleeding & replacing blood volume if needed→ assess for signs/sx of anxiety, restlessness, cold & clammy skin, weak/thready/rapid pulse, hypotension, deep/rapid respirations, increased thirst, decrease urine output ○ Thrombophlebitis/DVT / Pulmonary Embolism → focus on preventing clots with TED hose, SCDs, leg exercises & ambulation ■ PE → signs/sx : anxiety, restlessness, CP,dyspnea, cough, cyanosis, leg pain/swelling, dysrhythmias, tachypnea, tachycardia, hypotension ● Administer anticoagulants, analgesics, manage anxiety 9

● Bedrest, oxygen, elevate HOB ○ Pneumonia → assess for dyspnea, adventitious breath sounds, CP, chills, and fever ■ Encourage use of incentive spirometer ○ Atelectasis → collapse of all or part of lung ■ Assess for → cough, dyspnea, anxiety, CP, cyanosis, diminished breath sounds, & crackles ■ Administer → oxygen, analgesics as ordered, position in fowler or semi-fowlers, ambulation, hydration, cough & deep breathing, incentive spirometer, & turn q 2hrs ○ Wound Infection →   -

Diabetes ● Key Terms ○ Albuminuria → albumin in urine. Common sign of renal impairment ○ Gastroparesis → delayed gastric emptying that is a cause of hypoglycemia related to the mismatch of nutrient absorption and insulin action ○ Glucagon → counter-regulatory hormone that has actions opposite those of insulin. Prevents hypoglycemia, so increase BG ○ Gluconeogenesis → conversion of proteins to glucose ○ Glycemic → blood glucose regulation ○ Glycosylated hemoglobin A1C → standard test that measures how much glucose permanently attaches to the hemoglobin molecule ○ Hematuria → blood in urine ○ Hyperglycemia → high BG ○ Hyperinsulinemia → chronic high blood insulin levels. Can occur with intensive management schedules and may result in weight gain ○ Hyperkalemia → high K+...greater than 5.0 ○ Hyperlipidemia → high blood lipid levels (normal is 100-129 mg/dL) ○ Hypokalemia → less than 3.5 ○ Ketosis → metabolic state in which fat provides fuel for the body. Occurs when there is little access to glucose. Associated to ketogenic and low carb diets ○ Ketones → abnormal breakdown products that collect in the blood when insulin is not available; leads to acid - base balance problem of metabolic acidosis ○ Kussmaul Breathing → deep & rapid...cause respiratory alkalosis in an attempt to correct metabolic acidosis by exhaling carbon dioxide ○ Macrovascular → cardiovascular disease & cerebrovascular disease & reduced immunity

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○ Microvascular → eye & vision complications, diabetic autonomic neuropathy, diabetic neuropathy, sexual dysfunction, & cognitive dysfunction ○ Polydipsia → excessive thirst ○ Polyphagia → excessive hunger ○ Polyuria → excessive urination ○ Prandial → second phase of insulin release after eating ○ Proliferative Diabetic Retinotherapy → growth of new retinal blood vessels, neovascularization, when retinal blood flow is poor and hypoxia develops, retinal cells secrete vascular endothelial growth factors that stimulate formation of new blood vessels in the eye  ○ Diabetic Peripheral Neuropathy → progressive deterioration of nerve function that results in loss of sensory perception ○ Diabetic Nephropathy → pathologic change in the kidney that reduces kidney function and leads to kidney failure ○ Prediabetes → impaired fasting glucose or impaired glucose tolerance Simple Physiology ○ Eat food which causes blood sugar to rise which then triggers the pancreas to release insulin ■ Insulin allows glucose to cells ■ Triggers liver to convert glucose to glycogen ○ Low BG triggers pancreas to release glucagon to raise our BG ○ Insulin is the key that unlocks the door of the cell wall & lets glucose to go in What causes BG to rise? ○ Stress ○ Food ○ Medications → steroids, some antibiotics & oral contraceptives, diuretics & laxatives, cold medicine ○ Infection / Illness ○ Not taking diabetic meds ○ Changes in hormones → menstrual cycle ○ Minimal exercise taking in more energy than expending What lowers BG? ○ Exercise ○ Starvation ○ Medications -> warfarin, too much diabetic meds, alcohol, some antibiotics Prediabetes ○ Insulin resistance ■ Cell can’t quite use insulin correctly ■ Mild alteration to beta cell 11

○ Can prevent or delay onset of full blown diabetes with lifestyle modifications, weight loss, increased physical activity, & healthy diet ● Type 1 DM ○ Physiology ■ Inflammation of islets of langerhans in pancreas ■ Beta cells are destroyed resulting in absolute insulin deficiency ■ Hyperglycemia occurs when 80-90% if beta cells are destroyed ○ Etiology ■ Autoimmune disorder that destroys beta cells in the pancreas. Occurs in the genetically susceptible individual ■ Environmental factor (virus or chemical toxin) is a trigger that leads to destruction of beta cells ■ Children of type 1 diabetics have 2-5% chance of developing DM ○ Characteristics → juvenile onset, insulin dependent ■ Rapid onset ■ ~ 10% diabetics ■ Usually dx in childhood ■ ONLY treat with insulin ■ Ketotic → ketones are byproduct of fat metabolism ■ Often thin and underweight ■ Fatigue & malaise ● Type 2 ○ Pathophysiology ■ Insulin resistance ● Generally develops from obesity & sedentary lifestyle in a genetically susceptible person ● Cell resists insulin, so glucose is unable to move into the cell ■ Body tries to compensate ● Initially increases insulin secretion to overcome insulin resistance. This results in normal blood sugars but very high levels of insulin (hyperinsulinemia) ● Later, beta cells get tired & can’t keep up with increased demand for insulin. BG goes up, but insulin levels drops ■ Eventually need to ● Lose weight or increase exercise ● Begin oral medications or insulin ○ Risk factors ■ Family ● 15% risk if parents have DM 12

● 75% risk if siblings have DM ■ Obesity ● BMI > 27 ● Insulin resistance especially in upper body obesity (more visceral fat) ● Decreased number of available receptor sites for insulin ■ Sedentary lifestyle ■ Race / Ethnicity ● African americans, hispanics, native americans more than white ppl ■ Polycystic Ovarian Syndrome ■ Hx of gestational diabetes ■ Acanthosis nigricans ● Brown thickening of skin → indicates insulin resistance ○ Characteristics → adult onset, non-insulin dependent ■ Generally slow onset ■ May go undiagnosed without screening ■ Sx may be vague ■ 85-90% of diabetics ■ Usually dx in middle age / elderly ■ Treat with oral agents...