NRSG258 Study Guide PDF

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A-G! • ABCDE ‐ Primary assessment ‐ airway, breathing, circulation, disability, exposure! • FGH ‐ Secondary assessment ‐ fluids/full set of vital signs, glucose/ give comfort; head to toe! Body Systems! • Respiratory – Airway + Breathing! • CVS ‐ Circulation$ CNS ‐ Disability$ GIT – Diet/ Bowels! • Renal – Fluids in and out! • Integumentary – Exposure! Head to toe assessment! • General Status - vital signs, pain! • Neurological - coordination, reflexes, orientated! • Head, ears, eyes, nose, throat - colour and moistness! • Neck - palpate lymph nodes, range of motion! • Shoulder/arms - range of motion and strength! • Respiratory%- lung sounds front and back! • Cardiac - listen to heartbeat%! • Abdomen - listen for bowel sounds, palpate for pain/tenderness! • Legs/feet - range of motion and strength! • Skin - colour (pale, cold, hot, flushed); lesions, abrasions, rashes, lumps! Roper-Logan-Tierney! • Maintaining a safe environment! • Communication! • Breathing! • Eating and drinking! • Elimination! • Washing and dressing! • Controlling temperature! • Mobilisation! • Working and playing! • Expressing sexuality! • Sleeping! • Death! Factors affecting RLT! • Biological!

• Physiological! • Socio-cultural! • Environmental! • Politico-economic! Intra‐operative! • Maintain patient safety in positioning, specimen collection, surgical counts, maintaining sterile field, assist surgeon/anaesthetist or other staff as required; organize and pass equipment $ Education to reduce risk of post‐op complications by! • Wound splinting! • Deep breathing and coughing exercises (or huffing if patient cannot do DBC)! • Incentive spirometry! • Leg/foot exercises in bed and chair – dorsi/plantar flexion! • Early ambulation! • Repositioning! • PCA use and pain control! • Need for LMWH & anti‐embolic stockings! Types of surgery and settings! • Surgery! • Major surgery! • Minor surgery! • Endoscopic procedures! • Emergency! • Elective! • Settings and pathways for surgical admission! • Public hospitals! • Private hospitals! • Day procedure centres! • Specialist doctors surgeries – Specialists, palliative care centres! • Primary health care services e.g. GPs, optometrists, dentists! Consent! • Voluntary! • Specific to the procedure! • Informed in a language the patient can understand! • Legal capacity/competent – mental health, dementia etc.! Patient unsure and wishes to withdraw consent!

• What can you say? ! • Why don’t you want the surgery? ! • What has the doctor told you?! Inform the doctor of patients reasons! • Involves being able to meet the requirements e.g. age to provide consent! • Language issues! • Dementia! • Depression! • Pain! • Opioids prior to consent! • Any issues which impact on ability to be informed! Power of attorney! • Someone to look after your matters while you are away! • Person chosen must be over age of 18 and have full capacity! • General POA: you appoint someone to manage financial affaires, ceases immediately if you become unconscious! • Enduring POA: you appoint someone to manager financial affairs if you lose capacity! • Enduring medical POA: someone you appoint to make medical decisions when you lose capacity. This can be revoked at any time as long as you have mental capacity! Advanced Care Directive (ACD)! • Document made by person of wishes to receive if they no longer have the capacity! • Takes place of person’s verbal consent! • Cannot be overruled by family or medical or nursing staff! • Over-riding and ACD may lead to charges of assault/battery! The Coroner! • Is the person who is appointed to investigate cause of death (does not do autopsies)! • Death reports from a minor procedure where! • Death is unexpected! • Cause of death is unknown! • People who don’t have a name! • Someone that escaped from a mental facility and died! • Negligence! • Died in custody!

• Had not been attended by the doctor in the last six months! Respiratory system! • Potential issue - lower respiratory function; lower secretions & ability to exchange gases! • Interventions - encourage deep breathing & coughing; mobilisation; spirometry! • Abnormal cues - tachypnoea first sign of shock! Cardiovascular system! • Potential issue - arrhythmias; renal failure; risk of intra/post‐op bleeding/stroke; risk of PE! • Interventions - assess pre‐existing disease (HT, AF, etc.); assess medications; ECG & chest X‐ Ray; haemoglobin; monitor & record vital signs; clinical review if signs outside the ‘flags’! • Abnormal cues - tachypnoea is the first sign of shock; clinical review if signs outside the ‘flags’! Nervous system! • Potential issue - anaesthetics → altered level of consciousness! • Intervention - assess orientation/reorientate; provide reassurance; engage family for support! • Abnormal cues - agitation, confusion, restlessness, disorientation; worsening dementia ! Gastrointestinal system! • Potential issue - lower gastrointestinal motility and higher nausea! • Intervention - abdominal assessment; encourage fluids; record bowel movements; control nausea and vomiting with prescribed antiemetics! • Abnormal cues - paralytic ileus; gastric ulceration; constipation; vomiting! Fluids and electrolytes! • Potential issue - fluid & electrolyte imbalance! • Intervention - manage/record nausea, vomiting, diarrhoea, fluid intake and output! • Abnormal cues - electrolyte imbalances (hyponatraemia and hypokalaemia) leading to low or excess fluid volume! Urinary system! • Potential issue - anaesthetics can alter urinary function; inhibit urination!

• Intervention - monitor intake/output; strict fluid balance chart; SG urine (1.005‐ 1.035); monitor temperature for signs of UTI; assess for dehydration/overload! • Abnormal cues - post‐operative urinary retention; fluid/electrolyte imbalance; acute renal failure; UTI! Integumentary system! • Potential issue - anaesthetics decrease ability to maintain homeostasis and body temperature; increase disruption of skin integrity! • Intervention - changes in position every 2 hours; early mobilisation; pressure injury assessment; adequate protein intake; maintain body temperature! • Abnormal cues - poor wound healing/wound infection and/or tissue breakdown; pressure injuries; nerve injuries; hypothermia and cardiac arrhythmias ! Endocrine system! • Potential issue - stress on the body and negative nitrogen balance; immune system suppression; pain due to higher adrenaline/ noradrenalin (stress hormones)! • Intervention - assess wound healing; monitor and record intake/ output; maintain body temperature with warm blankets! • Abnormal cues - higher or lower BGLs; poor wound healing; fractures; GI haemorrhage; hyperglycaemia; hypothermia; can’t cope with stress; fluid/electrolyte imbalances! Medications! • Potential issue - higher levels of some drugs; some drugs can interact with some anaesthetic agents! • Interventions - monitor vital signs; know side effects of medications; observe patient and report adverse effects! • Abnormal cues - higher risk of bleeding; poor wound healing & ↑ risk of infection; hypotension! SMART goals! • Specific - what will the goal accomplish?! • Measurable - a visible outcome/impact or has the goal has been achieved?! • Achievable - is it possible to do successfully? Does the employee have the necessary knowledge, skills, abilities and resources to accomplish the goal?!

• Relevant/realistic - reason/purpose/benefit; what is the result?! • Time - expected completion date and does it give a sense of urgency! Risk factors for surgery! • Age: altered metabolism for drugs, older people with comorbidities, decreased muscle mass, decreased thirst receptors, increased risk of dehydration, poor wound healing, maintain body temp! • Nutrition: poor nutrition leads to poor wound healing, nutrients most important for recovery of wound healing is protein! • Lifestyle: smoking flattens cilia in trachea, decreased ability to expectorate mucous. Drug & alcohol withdrawal leads to post operative delirium, aggression! • Comorbidities: diabetes (inhibits immune system increasing infection and delayed wounds), hypothyroidism (decreased metabolism of drugs and ability to maintain normal body temp)! Pre-operative education! • How to splint wound – enables deep breathing and coughing and less strain ! • on wound leads to decreased dehiscence! • Deep breathing/coughing/huffing – air to alveoli helps improve atelectasis leading to! • increased venous return and decreased risk of VTE and chest infection! • Dorsiflexion and plantar flexion – increased venous return and decreased risk of VTE! • Low molecular weight heparin injections – prevent thrombosis formation leads to decreased risk of VTE! • Move side to side in bed – increased thorax and lung expansion and decreased risk of atelectasis and pressure injury! • How pain controlled postop (PCA use) – reduce fear of pain and provide sense of control! NSAIDs! • All NSAIDs should be avoided with other NSAIDS & anticoagulants! Aspirin Ibuprofen Prevents platelets becoming sticky

Blocks COX 1 and 2 leading to decreased prostaglandin formation

Blocks COX 1 and 2

Caution in asthmatic pt’s

May cause gastric ulcer and bleeding Pain scales! • Wong baker pain scale: faces developed by children! • Numeric pain score: self reporting 0-10! • Visual analogue scale! • Pain assessment – Abbey pain scale:! • For people who cannot verbalise! • Focus on visual points from pt, face, rubbing of body part, noises! Paracetamol Pharmacodyna Blocks mics prostaglandins in

brain

Ibuprofin

Morphine

Inhibits COX1 and 2 enzymes to decrease prostaglandins

Binds mu-opioid receptors in the brain, spinal cord and tissues with smooth muscle

Indication

Mild pain, fever

Mild pain due to inflammation, fever

Severe pain due to surgery, cancer pain

Adverse reactions

Very few reported

Rash, heartburn, stomach ulcers, gastric irritation, tinnitus

Sedation, respiratory depression, hypotension,

Asthma, hypertension

Liver/renal impairment

Hypersensitivity, GI bleeding

Hypersensitivity, acute asthma, respiratory depression

Precautions

Liver, renal impairment

Contraindicati Liver impairment/ ons failure, hypersensitivity

constipation

Pharmacology! •Pharmacokinetics:! • Drug absorption, distribution, metabolism, excretion! • Absorbed mostly in small intestine, although some absorption in stomach (alcohol, aspirin)! • Distributed bound to proteins in plasma – albumin made by liver! • Metabolised mainly in liver! • Excreted mainly by kidneys! •Pharmacodynamics:! • Chemical action (gaviscon)!

• Blocks enzymes (nurofen)! • Physical action (lactulose)! • Acts on receptors (Tenormin)! •Agonists: binds receptors and activates them! •Antagonists: binds receptors and blocks them! •Half life: time it takes to metabolise half the drug! •Therapeutic index: small different between the normal and toxic dose! Acute pain management! • Pharmacological! • Opioids, narcotics, NSAIDS, analgesics! • Non pharmacological! • Hot/cold packs, ice blocks, massage, acupressure, acupuncture! • Relaxation, deep breathing, exercise, art, play! • Distraction, imagery, hypnosis! Roles and Responsibilities! • Transfer to operating table then transfer to post‐anaesthetic recovery unit (PARU)! • Roles: anaesthetic nurse, instrument/scrub nurse, circulation/scout! • Maintain patient safety in positioning, specimen collection, surgical counts, maintaining sterile field, assist surgeon/anaesthetist or other staff as required; organise and pass equipment! • Postoperative – from admission to PARU to transfer of care. Continuous assessment required! • Provide advocacy and care for patient until patient has recovered from effects of anaesthesia! • Monitor the patient! • Performance of skilled assessment! • Communicate and liaise with the multidisciplinary team (MDT) and parents/guardians! • Provide report, transfer patient to another unit or discharge patient to home ! Anaesthetic drugs! • Work to depress neurotransmission of excitatory paths within the central nervous system and augment inhibitory signals to provide an adequate level of sedation! • Depending on the dose, it can be anywhere from 1-5 mg/kg or 7-12 mg/kg! • Hyperthermia, nausea, vomiting!

• Venous/arterial embolus, pneumothorax, acute intestinal obstruction with bowel distention, pulmonary air cysts, liver dysfunction, pheochromocytoma, contraindication in patients with severe asthma or active bronchospasm, contraindication with renal dysfunction! Week 4! Pain: is what the patient says it is! • Acute pain: productive, occurs immediately after damage – short term < 3 months! • Chronic pain: disease state, not connected to injury, difficult to treat – > 3 months! • Referred pain: transmitted from a part of the body that is not the cause of the pain e.g. cardiac pain felt in left arm! • Nociceptors: sensory nerve endings, heat, cold! • Tolerance: ability to withstand pain! • Threshold: point at which stimulus is perceived as painful due to activation of nociceptors! Inflammation! • First stage of healing! • Vasodilation! • Redness, heat, pain, swelling, loss of function! Wound healing! • Inflammation! • Organisation/proliferation! • Regeneration and fibrosis! Wound closure! Primary Intention Edges of wound brought together surgical incision closure

Secondary Intention

Tertiary Intention

Wound left open to heal from base up pressure injury

Wound left open to remove dirt, debris, organisms then surgical closure when wound is clean compound fracture

Discharge planning! • Include the patient and family ! • Discuss with patient and family ! • Describe home life! • Review medications!

• Recognise problems! • Explain test results! • Provide follow up appointments! • Educate family and pt! • Assess understanding! • Listen and honour goals and concern! General Anaesthesia! • Nitrous oxide (laughing gas): minor procedures, child birth, broken bones and long term exposure can affect DNA (may cause miscarriage)! • Propofol (general anaesthetic): short acting, rapid reversal, decreased nausea and vomiting compared to other anaesthetics! • 3 stages of anaesthesia:! • Analgesia to excitement to surgical anaesthesia! • Inhibits impulses to central nervous system and relaxes all muscles! • Emergence delirium may occur: wake up from anaesthetic confused and aggressive – could be linked to full bladder, withdrawal from alcohol or drugs! • Inhibitory never impulses to:! • Cerebral cortex! • Unconsciousness: amnesia; loss of motor control! • Medulla and pons! • Cessation of breathing and decrease of blood pressure! • Hypothalamus! • Decrease blood pressure! • Smooth muscle! • Tongue occludes airway! • Diaphragm! • Decrease breathing; decrease shivering; decrease body temperature! • Cardiac muscle! • Arrhythmias! Patient controlled analgesia (PCA)! • IV infusion controlled by patient of predetermined dose of analgesia! • Lock out devise so they cannot over dose! • Risks:! • Family interference! • Patient lack of understanding! • Benefits:! • No waiting for analgesia – better pain control !

• Decreased nausea & vomiting! • Reduces need for injection! • Pt has control over pain management! • Good pain management leads to increased mobility & deep breathing! Opioids! • All can cause nausea, constipation, agitation, anxiety, hallucinations, tachycardia, dizziness, headache, drowsiness and resp depression! • Do not drink or drive with! • Take a mild aperient from the chemist! Nuprenorphine Fentanyl Tramadol Codeine 7 day patches Severe, chronic, Moderate to for pain in cancer pain severe pain terminal cancer, opioid addiction

Mild pain combines with paracetamol

Antiemetic’s! • Metoclopramids! • Action – blocks dopamine receptors, increase peristalsis! • Side effects – dry mouth, sedation! • Adverse drug reactions – abnormal muscle contractions, e.g. twitching; restlessness; drowsiness! • Contraindications – epilepsy, Parkinson’s disease; GI! Nutrition! • Poor nutrition leads to weight loss and poor wound healing! • Main nutrition for healing is protein! • Carbohydrates! • Fats! Vitamins! • A: formation of tissues; good vision! • B: formation of red blood cells (anaemia)! • C: tissue repair, immune function (scurvy)! • D: absorption of calcium for bone formation (rickets)! • K: blood clotting (bleeding)! • Folic acid: normal formation of spinal cord (spina bifida)! Minerals! • Calcium: bones, teeth, nerve transmission, muscles, blot clotting!

• Sodium: nerve transmission, muscle contraction, h20 balance in circulation! • Potassium: nerve transmission, muscle contraction, g20 balance inside cells! • Iron: forms red blood cells! • Iodine: normal development of musculoskeletal and nervous system! Nutritional options! • Enteral nutrition: feeds bacteria in bowel to build immune system! • Parenteral nutrition: central line feeding, no functioning GI tract! Minerals! • Calcium: bones, teeth, nerve transmission, muscles, blot clotting! • Sodium: nerve transmission, muscle contraction, h20 balance in circulation! • Potassium: nerve transmission, muscle contraction, g20 balance inside cells! • Iron: forms red blood cells! • Iodine: normal development of musculoskeletal and nervous system! Nutritional options! • Enteral nutrition: feeds bacteria in bowel to build immune system! • Parenteral nutrition: central line feeding, no functioning GI tract! Obesity! • Increased perioperative morbidity! • May be malnourished from lack of nutrients and poor wound healing! • Adipose tissue have poor circulation but hold onto anaesthetic gases so may take longer to wake up and prolonged anaesthesia! • Difficulty mobilising increases risk of VTE, ateletctasis! • Strain on wound leads to dehiscence (wound popping open)! • Skin folds difficult to clean and dry causing wound infection! • Comorbidities: hypertension, high cholesterol, diabetes, cardiac complications, poor wound healing, diabetes! Stoma! • Pink and warm and protrude above the skin! • Haemoserous output for the first 48hrs! • Faecal output with return of peristalsis! • Colostomies and ileostomies: colostomy can have firm stool, ileostomy always liquid!

• Ileal conduit: take ureters and transplant into little tube of bowel that they have dissected, stoma comes out and urine output is continuous! • Paralytic ileus: peristalsis is stopped and no absorption of fluids! • Cause: bowel surgery, anaesthetic, low K+! • Assessment: N& D, distended abdo, no bowel sounds or movement! • Management: nil by mouth, NG drain tube, IV fl! Pulmonary embolus (PE)! • Thrombus (blood, air, fat) from veins travels to lung! • Blocks pulmonary circulation – bronchoconstriction; decrease gas exchange; atelectasis; infarcted lung! • Symptoms! • Chest pain, cough up blood, shock with low blood pressure, loss of consciousness, dyspnoea, tachypnoea, hypoxaemia, apprehension, haemoptysis, hypotension, loss of consciousness! • Management! • Positioning, ibuprofen, O2, analgesia, heparin, thrombolytics, thrombectomy! • Prevention! • Mobilisation, foot and leg exercises, TEDS, deep breathing! Management of IV cannulas! • Asses each shift for patency erythema, tenderness, pain, swelling, dressing integrity! • Review daily determine if still required and document in patient notes! • Routinely not in for longer than 72hrs, but can be longer than 72hrs if! • No signs of inflammation! • Difficult to reinsert and risk of remaining in situ less than retention! • Likely to be needed only for another 24hrs or less - remove IVC within 24 hrs if inserted without aseptic technique! IV fluids! • Concentration of blood measured by serum osmolarity – 290mosmol/ L! • Monitored and controlled by hypothalamus & anti-diuretic hormone ! • Normally plasma is isotonic with cells – equal H20 in an out of cells! • Dehydration increases osmolarity – h20 moves out of cells into circulation to maintain! • Fluid overload decreases osmolarity – h20 moves into cells! • IV fluids can be:! • Isotonic: no net movement of H20 in or out of cells (saline)!

• Hypotonic: more h20 moves into cells a...