HESI Review KEY MSI - Lecture notes PDF

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PERIOPERATIVE CARE 1. What is the role of the nurse in the preoperative phase? •

Assessing & teaching

2. What should you teach your patient in the preoperative phase? • •

What they will see when they wake up à lines, drains, splints, IV’s, etc. Things to do to prevent complications after surgery à IS, early ambulation, SCD’s, etc.

3. What do you assess for in the preoperative assessment? •

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Risk factors, allergies, medications (OTC, herbal, prescriptions, recreational drugs, alcohol, tobacco, dietary supplements), patient’s baseline (VS, BS, lung sounds), PMH (health problems, any issues with prior surgeries, personal or family issues with anesthesia) Specific allergies to assess for is latex & iodine o Latex food allergy associations – chestnuts, eggs, avocado, bananas, kiwi o Iodine food allergy associations – shellfish

4. Risk Factors (explain why they are risk factors) • Diabetes o Increased risk for infection, delayed wound healing, higher BS levels because of stress on body • COPD o Poor oxygenation, poor gas exchange • HTN o Increased risk for stroke, if too high surgery will NOT be done • Obesity o The body has a hard time clearing out the anesthesia, delays recovery • Smoking o Lungs damaged – lungs will not expand fully causing retaining of secretions which could lead to lung infection (pneumonia, URI) • CKD o Not able to filter out anesthesia, fluid overload due to isotonic solutions • Anxiety o Death, pain o Make sure you ask why they are anxious (education may help decrease anxiety) o Fear of death = no surgery o Address concern

5. What are some important labs to look at in the preoperative phase? What does each lab assess for? • WBC à infection (4.5-11) • H/H à assesses volume (could assess for dehydration, hemorrhage) • Plts à how well the patient will clot, will assess bleeding risk (150-400) • BUN (8-25) & Creatinine (0.6-1.3) -à KIDNEY FUNCTION **I listed lab values that I think are MOST likely to be tested** Informed Consent 6. Who is responsible for explaining the procedure, complications, and teaching risks & benefits? Surgeon 7. Who is responsible for obtaining signature? Nurse 8. What is in the preoperative checklist? • ID bracelet (right patient) • Allergy band • Baseline VS • Labs • H&P • Signed inform consent • Blood type & crossmatch • NPO status • Valuables 9. What is the role of the nurse in the intraoperative phase? PATIENT SAFETY!!! Comfort the patient 10. What do you need to check during a time out? • • • •

Make sure everything is correct!! Right site marked Informed consent, H&P, allergies DONE RIGHT BEFORE PROCEDURE BEGINS

11. Intraoperative Complications (explain each…like S&S, interventions) • Hypothermia o Cover with warm blankets, warm IV fluids to help prevent • Anaphylaxis o S/S à hypotension, bronchospasms (wheezing), pulmonary edema (fluid in lungs – crackles, gurgling sound), tachycardia, elevated RR • Aspiration o Turn on side, manage N/V

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F/E Imbalances Fluid Pouring Malignant Hyperthermia o S/S à tachycardia (EARLY SIGN), increased CO2, rigid muscles, tachypnea, fever (LATE SIGN) o Usually from succinylcholine – ANTIDOTE IS DANTROLENE Environmental complications o Fire because of volatile gases in OR

12. What is the role of the nurse in the postoperative phase? Prevent complications (airway & stable VS are priority) 13. Postoperative Complications (explain each) • Atelectasis o Most common complication that occurs 24 hours after surgery o S/S à dyspnea, tachypnea, decreased breath sounds, restlessness, crackles o Prevention à deep breathing, IS, TCDB, ambulation, ROM, huff cough o Treatment à give O2, High Fowler’s, pulse ox, do all interventions • Hypovolemic Shock o Most common complication 0-24 hours after surgery o Causes à bleeding/fluid loss o S/S à low BP, high HR, high RR o Interventions à pressure to wound, Trendelenburg position (gets blood to vital organs), administer fluid or blood, notify MD (LAST) • Infection o Occurs day 3 & on after surgery o Does not happen overnight o S/S à REDA (redness, edema, purulent drainage, approximation), tachycardia, increased WBC o Prevention à good hygiene, antibiotics, wound care, dressing changes, aseptic technique • Dehiscence & Evisceration o Dehiscence à wound open o Evisceration à organs protrude o Interventions à cover with MOIST dressing, Low Fowler’s position with knees bent, call MD • Pulmonary Embolism o S/S à impending doom, sudden chest pain, low HR, high RR, dyspnea, red, warm, swollen o Treatment à blood thinner, heparin o Interventions à High Fowler’s, O2, bed rest, call MD

DIABETES MELLITUS 14. What does insulin do?

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Insulin carries glucose out of the vascular space into the cell Insulin breaks down glucose, so when there is no insulin glucose can’t be broken down, causing increased glucose levels

15. Pathophysiology for Type I & Type II diabetes? • Type I o Autoimmune o Beta cell destruction o Pancreas makes NO insulin •

Type II o SOME insulin is made by the pancreas but not enough o Insulin resistance

16. Assessment findings for Type I & Type II diabetes? • Type I o 3 P’s à polyuria, polyphagia, polydipsia o Weight loss •

Type II o 2 P’s à polyuria & polyphagia o Prolonged wound healing o Weight gain or weight loss o Recurrent infections (yeast or UTI)

17. What are the diagnostic tests for diabetes? • Fasting Blood Sugar (FBS) o Usually the 1st test • • •

Casual Blood Sugar – fingerstick Glucose Tolerance Test o Give patient glucose drink, wait 2 hours and then test BS HgA1C (glycosylated Hgb) o 1st time diabetic patient it will be high o Long time diabetic à What does it mean if this is high? POOR CONTROL

18. What is the ONLY treatment for Type I diabetes? INSULIN

19. What are the treatments for Type II diabetes? • Insulin • Oral antidiabetics • Diet • Exercise 20. Education • Sick Day Rules o BS rises when sick, so monitor it more closely & may need more

insulin

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Foot Care o Diabetic shoes o Daily inspection (use mirror) o Nail trimming ONLY done by podiatrist Rule of 15’s o For HYPOGLYCEMIA o 15g of carb (fruit juice), recheck BS in 15 minutes, if BS 250, ketonuria, N/V, Kussmaul’s respirations, acetone odor to breath HHNKS (usually Type II)

22. Long term complications (explain what they mean) • PVD à loss of limbs • Retinopathy à vision loss • Neuropathy à loss of feeling in extremities • Angiopathy à MI, CHF, CVA • Nephropathy à ESRD • Infections

**ALL DUE TO POOR PERFUSION & NOT TAKING CARE OF THEMSELVES**

PULMONARY DISORDERS 23. Blood gas analysis (usually at least 1 question) • pH à 7.35-7.45 • CO2 à 35-45 • CO3 à 22-26 24. Review respiratory alkalosis/acidosis & metabolic alkalosis/acidosis

25. Pneumonia • Pathophysiology o Infection of lung

Exposure to foreign matter à inflammatory response à capillary walls become “leaky” à fluids shifts from capillaries, to interstitial space, then alveoli à alveoli fill with fluid à lung tissue consolidates à poorly oxygenated blood returns to heart & leads to arterial hypoxia Assessment Findings o Dyspnea, elevated WBC, fever, chills, tachycardia, tachypnea, pleural pain, respiratory distress, decreased breath sounds, crackles Diagnostics o Sputum culture – do before starting antibiotic o WBC à indicates there is an infection somewhere o CXR à will show there is something in lung o Bronchoscopy – last resort Treatment - antibiotics Interventions – O2, IS, hydration, TCDB, huff cough, semi-fowler’s o

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26. Tuberculosis (AIRBORNE PRECAUTIONS & HIGHLY CONTAGIOUS) • Assessment Findings o Blood tinged sputum, night sweats, weight loss • Diagnostic Tests o Mantoux Skin Test = exposure

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§ Once positive never can get again, will get CXR instead o CXR o Positive Acid-Fast Bacilli = confirms Treatment o 6-12 months o Isoniazid (INH), Rifampin (orange bodily fluids & use other form of birth control), Pyrazinamide, Ethambutol à MONITOR LIVER ENZYMES BECAUSE ALL CAUSE LIVER TOXICITY Education o Isolation in negative pressure room o Will be in isolation until 3 negative AFB tests o Medications

27. Asthma • Pathophysiology o Body has allergen à body reacts by coughing/sneezing à body

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then creates mucus to protect/cover things à blocking of airway à need to get rid of mucus to breathe o Triggers Assessment Findings o Wheezing, coughing (1st sign of improvement & worsening), SOB Treatment o Bronchodilator § Give 1st o Inhaled Corticosteroid § Rinse mouth after use

28. COPD • Pathophysiology o Air gets trapped in the lungs & converts to CO2, the patient • • •

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stops breathing because of too much CO2 Assessment Findings o Barreled chest, thin, tripod positioning Interventions o Pursed lip breathing, O2, high calorie & frequent small meals Education o Steps to prevent & control acute attacks à pursed lip breathing, inhaler, diaphragmatic breathing, tripod position o Effective coughing à cough technique, adequate fluid intake to thin mucus o Conserving/maximizing à exercise, pace daily activity, simplify tasks o Minimizing exposure à use humidifier, avoid triggers o Prevent à recognize early signs of infection, annual flu shots, quit smoking, pneumonia vaccine Oxygen Toxicity o S/S à respiratory distress, get worse when increasing O2 levels instead of getting better, confusion, hallucinations, fatigue, anxiety, restlessness, 6L & sleeping well o Prevent à start w/ lowest level of O2 possible

MUSCULOSKELETAL DISORDERS 29. What is a sprain & a strain? • Sprain à injury to the ligaments surrounding a joint, caused by a wrenching or •

twisting motion Strain à an excessive stretching of a muscle, fascial sheath, or a tendon

30. Interventions for soft tissue injuries (sprain, strain)? • RICE à rest, ice, compression, elevation • Heat pads à after 48 hours for no longer than 30 mins at a time • Ice à start w/ first for 24-48 hrs for 20-30 mins at a time • Compression à 30 mins on & 15 mins off • Elevate à 24-48 hrs to reduce edema 31. What are the 6P’s of the neurovascular assessment? • Pain • Pallor • Pulselessness • Pressure • Paresthesia • Paralysis

32. Fracture • Assessment Findings o Continuous pain, muscle spasms (larger bones), edema, •

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deformity, crepitation, loss of function Interventions o IMMOBILIZE o Neurovascular assessment o Open fractures à cover with sterile dressing o Immobilize to support fracture & decrease movement to prevent further damage & prevent spasms; also helps maintain the vascular nature of injury so you don’t have pallor or pulselessness o Splinting = helps prevent spasms Goals o Maintain alignment/reduction o Immobilization § Buck’s Traction à most commonly used for hip fx USED PREOPERATIVELY • Manually immobilizes until they have surgery – once they have surgery they won’t be in this • Uses skin to immobilize • NEED TO DO GOOD SKIN ASSESSMENTS BECAUSE AT INCREASED RISK FOR PRESSURE ULCERS • GOING TO BATHROOM = USE TRAPEZE BAR TO LIFE SELF OFF OF BED TO REMAIN IN TRACTION & USE BED PAIN (GOOD TIME TO ASSESS SKIN) • **Make sure weights ALWAYS hang freely** • Weight on floor = raise the HOB • Traction off = call MD à if you are not competent to put on traction, go get someone who is so they can fix it • NEVER LOOSEN TRACTION OR TURN PATIENT • USED TO PREVENT FAT EMBOLI § Skeletal à used when prolonged traction is necessary • Complications à infection, immobility • Skin care à clean crusts, serous drainage is okay, skin care is aseptic not sterile

Mobility à prolonged immobility is a MAJOR DISADVANTAGE** • If pin comes out, COVER IT, CALL MD • AT HIGH RISK FOR OSTEOMYELITIS BECAUSE PINS GIVE DIRECT ENTRY TO BONE FOR PATHOGENS o Restore function •

33. What should you teach about casts? • Elevate • Hot spots – infection • Hairdryer/ice packs if itching occurs – DO NOT STICK ANYTHING IN CAST

34. Compartment Syndrome (circulation issue) • Assessment Findings o Pain that does not go away with pain medication, 6P’s 35. Fat embolus • What kind of fractures are the most common cause? Long bone (femur) or pelvic • •

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bone When are they most likely to occur? 24-48 hours after injury S&S o Petechiae on chest*, impending doom, SOB, decrease O2, Hgb, & Hct decreased Interventions o O2, fluids

36. Osteomyelitis • Pathophysiology o Bone infection • Risk Factors o Diabetes, open fractures, immunocompromised patients •

Treatment o Long term IV antibiotics

37. Osteomalacia • Pathophysiology o Soft bone o Low vitamin D •

Interventions (think diet) o Want to increase Vitamin D & Calcium o Diet à eggs, oily fish, meat, vitamin D supplements

38. Osteoporosis • Pathophysiology o Brittle bones, low bone mass • • •

Risk Factors o Older age, women, menopause, smokers Assessment Finding o Fractures easily, kyphosis (humpback) Diagnostic Tests o Bone mineral density test o T-score

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Treatments o Bisphosphonates, increase vitamin D, weight-bearing exercises

39. Osteoarthritis • Pathophysiology o Cartilage destruction/damage o Gets worse throughout the

day Lower extremities & larger joints mainly affected Assessment Findings o Crepitation o Pain that gets worse with use o Asymmetrical joint involvement Interventions o Exercise, rest, decrease weight, splints, heat, ice pack o

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40. Rheumatoid Arthritis • Pathophysiology o Autoimmune

Pain gets better with use Usually affects smaller joints, like hands Assessment Findings o Stiffness in the morning, ulnar drift, symmetrical joint involvement o o

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41. Gout •

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Pathophysiology o Increase in uric acid o Body makes UA when it breaks down purines o Too many purines in diet = more UA production Treatment o Allopurinol Complications o Renal issue because UA is hard on kidneys IMMUNE DISORDERS (not likely to be tested)

42. Lupus • Pathophysiology • Assessment Findings • Education 43. HIV/AIDS • Pathophysiology o HIV enters the bloodstream à binds to protein receptors of

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CD4+ cells & enters the cell à reverse transcriptase creates HIV RNA to DNA à HIV uses integrase to place itself into host cells genetic code à all daughter cells are infected à HIV spreads à apoptosis occurs in CD4+ cells à immunodeficiency Transmission o Sexual transmission o Contact with bodily fluids o Needle sticks Diagnostic Tests o ELOSIA § Used to diagnose o Western Blot Test § Confirms diagnosis o Others

§ WBC § CD4 count à PROGRESSION • Stages (Normal CD4 500-1200) o Acute (primary) Infection à occurs 2-4 weeks after a person becomes infected § High viral load – body is trying to figure out what is going on § Highest risk to spread o Asymptomatic Phase à CD4 remains above 500 § Viral load is a little lower o Symptomatic Phase à CD4 ranges from 200-499 § Viral load increases again o AIDS à CD4 10 B/C RISK FOR BLOOD CLOTS, DO NOT GIVE IF BP IS HIGH o Iron Deficiency Anemia § What is this caused by? Decreased iron § Interventions? • Oral iron supplements • Liquid iron à use straw because will stain teeth • Foods à beans, greens, eggs, apricots, tofu, red meats • Give iron on empty stomach or with Vitamin C to help with absorption o Cobalamin/Vitamin B12 Deficiency § Caused by a lack of what? Vitamin B12 § Interventions? Give B12 SQ o Folic Acid Deficiency § Caused by? Low folic acid § Interventions? Diet high in folic acid o Aplastic Anemia § What do lab values look like? Low RBC, Hgb, Hct, WBC, & Plt § Interventions? Blood transfusion, prevent infection, neutropenic precautions, bone marrow transplant § What precautions do you take? • Bleeding – soft toothbrush, no IM injections • Neutropenic o Mask, gown up if going into patient room, if patient comes out of room mask the patient o No flowers, no fast food, limit visitors, good hand hygiene, should not have fresh fruits & veggies

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Increased Destruction of Erythrocytes o Hemolytic Anemia § Pathophysiology? • Destruction of RBC’s exceeds the production of RBC’s

The body starts attacking its own RBC’s and cause them to lyse § Assessment Findings? • Jaundice because increased destruction of RBC’s causes an elevation in bilirubin levels • Splenomegaly, fatigue, dyspnea § What is the main focus? • Maintaining renal function o Sickle Cell Anemia § How are the RBC’s shaped? Sickled § Assessment findings? • PAIN, low RBC & H&H because the cells can’t carry as much as normal full cells § What are some triggers? • Stress, infection •

47. What is hemochromatosis and what is the intervention for this?

Too much iron, phlebotomy *Can cause liver scarring* 48. What is polycythemia vera and what is the intervention for this?

Too many RBC’s (can cause organ failure because organs are being perfused properly), phlebotomy 49. Neutropenia • What will WBC lab look like? Low...