NUR 340 exam 1 study guide PDF

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Study Guide concept review for test #1...

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NUR 340 Exam 1 Test Map

Labs and diagnostics (must know normal values for labs marked with an asterisk – see Hinkle p 694, Table 25-4 for standard normal values) 

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Thyroid studies o Assist in diagnosing autoimmune thyroid disease and separate it from other forms of thyroiditis o TSH evaluates thyroid dysfunction T4 o Thyroxine, evaluates thyroid function T3 o Elevated if hyperthyroid

**Electrolytes: 

Sodium- hyponatremia indicate fluid excess and can be caused by heart failure or administration of thiazide diuretics. Hypernatremia indicate fluid deficit and can result from decreased water intake or loss of water through excessive sweating or diarrhea o Muscle contraction, nerve impulses, regulation of acid base Assess: sodium sources, I and O, edema, weight  135-145 Potassium- major role in cardiac function o 3.5-5.0 Liver function studies o Bilirubin measures the livers ability to conjugate and excrete bilirubin, allowing differentiation between bilirubin in plasma  No fasting or special prep is required o

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Complete blood count (CBC)  

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identifies the total # of white and red blood cells, platelets, hgb and hct, general health, screen for anemia, infection, inflammation, bleeding disorders, cancer RBC** o Increased level assess fluid balance and respirations o Decreased level assess fatigue, VS, diet, injuries (possible blood loss)  4.3-5.7 (m), 3.8-5.1 (f) Hgb ** o Transports oxygen to the cells and carbon dioxide to the lungs  Decrease levels of hgb and hct can indicate blood loss or dilution of circulating volume by IV fluids (anemia, hemorrhage, hemodilution)

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13-18 (m), 12-16 (f)

Hct ** o The % of RBC found in whole blood  42-52% (m), 35-47% (f) WBC ** o Indicate infection, monitored in immunocompromised people and those when there is a concern for infection (surgery)  4,500-11,000 Platelets ** o First line of protection against bleeding, they undergo changes to form a thrombus  If decrease in platelet level assess for bruising and bleeding  150,000-450,000 Serum creatinine ** o Used to assess renal function, increase in creatinine indicates renal impairment. o A normal creatinine level and increased BUN suggest an IV fluid volume deficit  0.7-1.4 Calculated creatinine clearance o Best information about potential for increased circulating drug levels, 24-hour urine test GFR o Test that detects how well the kidneys are working, estimates how much blood passes through the glomeruli (filter waste from blood) each minute Blood urea nitrogen (BUN) o End products of protein metabolism excreted by the kidneys Elevated BUN reflects reduced renal perfusion from decreased cardiac output or IV fluid volume deficit as a result of diuretic therapy or dehydration  10-20 Prothrombin time/INR o measures the extrinsic pathway activity and is used to monitor the level of anticoagulant with warfarin, diagnose bleeding and clotting disorders o the INR provides a standard method for reporting PT levels and eliminates the variation of PT results. Monitors the effectiveness of warfarin Fasting glucose (70-110 mg/dL.) ** o Fasting for 8 hours o

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General Content topics: 

Surgical environment o Unrestricted Zone  Street clothes, family visits, patient waiting area o Semi-restricted Zone

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 Scrub clothes and cap; no street clothes, hallway between waiting room and OR o Restricted Zone  Scrub clothes, shoe covers, caps and masks; new mask each time, cannot hang around neck o Is considered effective if there is a decrease in HAI Roles and responsibilities of surgical team members o Anesthesiologist o Surgeon  Obtains informed consent, surgical time out o Nurses  Be the patient advocate  Circulating nurse  Not sterile, coordinator, makes sure equipment works, documents surgery  Scrub nurse  Sterile, sets up sterile field, hands surgeon tools, counts sponges o Sponge, needle and instrument count: once before surgery and twice after surgery Physical layout of surgical area including purpose Aseptic technique including surgical hand hygiene o All materials in contact with the surgical wound or used within the sterile field must be sterile o Gowns considered sterile in front from chest to level of sterile field, sleeves from 2 inches above elbow to cuff o Movements of surgical team are from sterile to sterile o Movement at least 1 foot distance from sterile field must be maintained o Incision is the central part of the sterile field National Patient Safety Goals o Sentinel event: wrong site surgery  Wrong patient, site, procedure  Highest patient safety priority o Must identify pt using 2 ways  Ask pt name dob, look at medical record # and compare that # with chart o Improve staff communication  Report tests and diagnostic procedures results to appropriate person in timely manner o Use medication safetly  Label meds not given immediately

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Compare current medications with those taken by pt before admission  Medication reconciliation Prevent infection Prevent mistakes in surgery  Pre-procedure verification process  Surgeon, with pt involvement, marks surgery site  Make sure correct surgery is done on correct body part of correct patient  Surgical time out  Pause before surgery to make sure a mistake is not being made  Verify pt identification, surgical procedure, and site before anesthesia is administered

Surgical Care Improvement Project & Quality Indicators for Surgery o Antibiotic given 1 hour before incision and stopped 24 hours after surgery end time o Cardiac pt have controlled 6am blood glucose post-op o Indwelling cath removed POD1 or POD2 o Perioperative temperature management Perioperative patient assessment o Health history, family history, physical assessment and baseline established prior to surgery o Ask patient about use of OTC, Herbal medications, supplements and prescription drugs being taken o Activity and functional levels determined o Known allergies to drugs, food, and latex  If patient has allergy, ask what type of reaction they have o Nutritional and fluid status  Nutritional deficiencies can influence wound healing  Fluid and electrolyte imbalances need to be corrected prior to surgery o Dentition o Drug and alcohol use  Weaken patient’s immune system and increase risk for post-op complication Preadmission Testing (PAT) 1. Initiates initial preoperative assessment 2. Initiates education appropriate to patient’s needs 3. Involves family in interview 4. Verifies completion of preoperative diagnostic testing 5. Verifies understanding of surgeon-specific preoperative orders a. Bowel preparation, preoperative shower

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6. Discusses and reviews advance directive document 7. Begins discharge planning by assessing patient’s need for postoperative transportation and care Informed consent o A surgical permit, legal document o Responsibility of the physician to obtain consent, the nurse is the witness and patient advocate  Consent can be revoked at any time o Consent can be overridden in emergency Patient care throughout perioperative experience including psychosocial needs and physiological parameters o Explaining procedure and answering patient questions can help decrease pre-op anxiety and fears o Identify patient’s support network Types of anesthesia, benefits and potential adverse effects Pain management o PCA o Analgesics- topical, oral, opioids o Assess pain frequently  Encourage patient to ask for meds before pain gets severe  Provide analgesia 30 minutes before ambulation or other painful procedures  Provide scheduled meds rather than PRN routine Wounds o normal healing  first-intention wound healing- minimal tissue destruction, paper cut or scalpel incision  initial  granulation o chemicals released to tighten edges of wounds  pink, vascular, fragile  maturation o scar formation  Appearance o Slightly crusting along incision line, pink incision color, slight swelling or puffiness under suture  Inflammatory response o dehiscence  wound opening due to pocket of infection popping open

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apply non-adherent wound dressing and tell patient to avoid pressure o notify surgeon

evisceration  Organ protrudes through wound opening  Place pt in low fowler’s position, cover with sterile saline moistened gauze, take frequent vital signs, notify surgeon  Pain and vomiting can cause this  Prevent using abdominal binder drainage tubes

Risks and special precautions 

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Alcoholics o More anesthetic agent, assess amount of intake and when last drink was withdrawal in post-op, weakened immune system for healing Obesity o Respiratory issues, thicker skin, cardiac insufficiency, HTN, diabetes, CAD, avoid fat soluble medication; anesthetics are stored in the adipose tissue so they may linger longer, assess ventilation and RR, LOC and sedation Smoking o Lung issues, increases sensitivity to neuromuscular blockers, assess lung sounds and vitals pre-and post, stop smoking 30 days prior to surgery to prevent complications Patients with disabilities o The need for assistive devices, modifications in pre-op education, and additional assistance with positioning and transferring  Assistive devices include hearing aids, eyeglasses, braces, prostheses  Interpreter and alternative communication is necessary for disabled patients to understand the procedure and teaching o Patient with a disability that affects body positioning may need special positioning during surgery to prevent pain and injury  Patient may be unable to sense painful positioning or communicate their discomfort o Patients with respiratory problems r/t to a disability may experience difficulties unless the problems are made known to the anesthesiologist or CRNA to make adjustments Geriatrics o Older adult patients have less physiological reserve  Greater risk, comorbidities, drug interactions and adverse effects of medications due to organ function, monitor liver, CK, creatinine functions, GFR most reliable, decrease capillary refill, more sensitivity to fluid and blood loss, electrolyte disturbances, immune and stress response weakened, observe overall status

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Respiratory and cardiac complications are the leading causes of postoperative morbidity and mortality in older adults

Intra & Postoperative complications: 

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Anesthesia Awareness o Only general anesthesia renders state of complete unconsciousness o It is the unintended intraoperative awareness  Recalling events in OR while under general anesthesia o Indications  Increased BP, increased HR, patient movement  Medication may mask vital sign changes o Prevention  Use of meds with amnesic effect  Avoid neuromuscular blockers except when necessary  Paralytic agents N&V o Caused by anesthesia and pain medication o If gagging occurs during surgery  Turn patient to side, lower HOB, suction is used to remove saliva and gastric contents  Pt may be given antiemetic pre-op or intra-op to counteract aspiration Anaphylaxis o Patients have already developed antibodies to a foreign substance and develop a systemic reaction which triggers an inflammatory response resulting in widespread vasodilation, capillary permeability  Causes: medications and latex  Can be immediate or delayed  Prevention is key  Identify those at risk  Assess allergies and products in the OR  Early recognition  Three defining characteristics  Acute onset of symptoms  Cardiovascular compromise  Presence of two or more o Respiratory compromise o Decreased BP o GI distress o Skin or mucosal irritation

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Flushing, Urticara, angioedema, hypotension, tachycardia, bronchoconstriction  Can be masked by anesthesia  Treatment  Remove causative agent  Notify MD  Airway support, O2  Give Epinephrine STAT to increase BP  Diphenhydramine  Corticosteroids to stop inflammation **priority intervention is the ABCs Hypoxia, Respiratory Depression, Atelectasis, Pneumonia o Inadequate ventilation, occlusion of airway, inadvertent intubation or esophagus, and hypoxia are potential complications associated with general anesthesia o Anesthetic agent can cause respiratory depression (decreased RR)  Brain damage from hypoxia occurs within minutes  Continuous monitoring of oxygenation status, peripheral perfusion and pulse oximetry  Secure airway and monitor medication o Atelectasis  Alveoli secret mucus and stick together, lungs don’t inflate all the way o May hear crackles o Incentive spirometer, deep breathing and effective cough very important Hypothermia o Body temperature drops very low during surgery, causes vasoconstriction which increases the stress on the body  May cause metabolic acidosis o Place heated blanket on patient and give warm fluids, remove wet gowns and drapes promptly and replace with dry ones, minimize the area the patient is exposed  Warming must be done gradually, not rapidly o Monitor core temperature, urinary output, ECG, BP, ABGs, and electrolyte levels Malignant hyperthermia o Hypermetabolism of skeletal muscle r/t high release of calcium o Triggered by anesthetic agents  Volatile inhalation aesthetics  Neuromuscular blocking agents  Succinylcholine o Risk Factors  Strong bulky muscles  Hx muscle weakness or muscle cramps

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Unexplained temperature elevation Unexplained death of family member during surgery accompanied by febrile response  Family history o Clinical Manifestations  Early signs: tachycardia, hypercapnia, rigidity, ventricular dysrhythmias, hypotension, cardiac arrest  Late sign: elevated temperature o Treatment  Stop triggering agent  Dantrolene sodium IV  Reversal agent  Treat symptoms  Oxygenation, hyperventilation, hydration, cooling  Monitor patient at risk for and have medication ready Infection o Pathogenic organisms grow and spread, cannot be controlled by body’s immune defense  Keep sterile field, give antibiotic 1 hour before incision and stop antibiotic 24 hours after surgery  Monitor surgical site, temperature, antibiotic orders LAST o Local Anesthetic Systemic Toxicity  Overdose, local medication absorbed systemically o Rare; severe and life threatening o Generally, occurs 1-5 minutes after injection, may be delayed for as long as an hour o Symptoms:  Analgesia, circumorally numbness, metallic taste, tinnitus, agitation  seizure activity CNS depression (coma, respiratory arrest, ventricular dysrhythmias, & cardiovascular collapse) o Treatment  Stopping injection of the anesthetic immediately and attend airway management  Lipid emulsion therapy w/ 20% lipid emulsion is an antidote  Treat signs and symptoms  Seizure suppression, manage dysrhythmias, hypotension, cardiac arrest Thrombosis: DVT o Causes/risk: dehydration, low CO, blood pooling in extremities, bed rest o S/S: initially pain or cramping in the calf, then swelling, fever, chills, diaphoresis o Treatment: prophylactic treatment or anticoagulants, compression stockings

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 Early ambulation and leg exercises and adequate fluid intake Hemorrhage o Hypotension  Caused by un-replaced fluid and blood loss  Decreased cardiac output; interventions to promote adequate CO o hypervolemia  Insufficient blood volume leads to vasoconstriction and reduced oxygen and nutrients available for wound healing  Monitor for volume deficit (circulatory impairment), correct by fluid replacement o Shock  Hypotension, increased HR and RR, decreased urine output, cool and pale skin Bleeding (Promoting cardiac output) o IV fluid replacement, close monitoring to detect and correct conditions such as fluid volume deficit, altered tissue perfusion, and decreased CO.  Monitor strict I &O o Assess patency of IV lines and ensuring the correct fluids are given at the prescribed rate, strict I & O are measured and recorded, urinary output should not be less than 0.5 ml/kg/hr. Monitor hgb, hct and electrolyte levels.

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Discharge criteria o Baseline mobility, transportation, N/V and pain controlled, off IV opioid, support system o Provide written & verbal instructions  Follow-up care, appointments, wound care, activity, restrictions, diet, medications, complications  Patients are not allowed to drive themselves home or be discharged to home alone

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Patient/Caregiver Teaching o Patient has a right to know what to expect  Increases patient satisfaction  Reduces fear, anxiety, stress, pain and vomiting o Educate on prevention of post-op complication  Cough and deep breathing, incentive spirometry, active ROM, mobility, pain management Teaching/Learning Strategies o Demonstration, teach-back, verbal and written

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NUR 340 Exam 1 Test Map Adult learning principles: also identify special needs groups (i.e. cultural differences, older adults, low literacy) Evaluation techniques

Pharmacology: See Homework 1 Perioperative Pharm Table list. GENERAL ANESTHESIA 

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Inhaled anesthetics (Isoflurane, desflurane, sevoflurane [‘flurane sisters]) o Used for rapid induction and emergency, pt awake in 10 minutes o Patient receives 100% oxygen in PACU to eliminate anesthetic  Eliminated through the lungs o Given in combination with oxygen and nitrous oxide o Action:  Produces amnesia, skeletal muscle relaxation and hypnosis  As concentration increases, BP decreases, HR and RR increase o Adverse Effects:  Cardiac and respiratory depression  Airway irritation and coughing  Reduces renal blood flow (dehydration)  Malignant hyperthermia o Interactions:  Alcohol, Kava, St. John’s Wort, Valerian Root  Increase the effects o Nursing Implications:  Secure airway  Provide O2, frequently assess BP, quality of breathing or ventilation  Give patient warm blanket post-op  Provide medication for post-op N/V  Notify anesthesiologist immediately if you notice any s/s of MH Intravenous Anesthetics o Render a patient unconscious in a fast and safe manner o Action:  Produces amnesia, euphoria and hypnosis  Does not provide analgesia  Has anticonvulsant properties

NUR 340 Exam 1 Test Map  Decreases BP, cardiac output and respiration rate  Produces bronchodilation, therapeutic for patients with asthma or COPD o Propofol  Amnesia, euphoria, hypnosis; no analgesic effect Additional meds: Avoid general anesthesia for many co-morbidities 

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Epinephrine o Vasoconstrictor, helps anesthetic last longer, anaphylaxis, keeps local  If epinephrine goes systemic pt. may be tachycardic, anxious, restless Atropine o Speeds HR up if patient goes bradycardic o Given Pre-op to decrease secretions  Decrease risk for aspiration Dantrolene o Decreases muscle rigidity due to malignant hyperthermia Herbal Supplements (Abrams’ Table 3.6, Box 3.6; See Perioperative Pharmacology PP) o Can potentiate or negate effects of medication o Kava, St. John’s Wart, Valerian Root  Can cause excessive sedation  Give less anesthesia o St. John’s Wort  Decreases serum concentration of lidocaine o Ginger  Can increase clotting time  Risk for bleeding o Garlic, Gingko, Feverfew, Chamomile  Increase risk of bleeding o Ginseng  May increase BP Opioids o Side Effects: hypotension, respiratory depression, sedation, constipation Opioid antagonist: naloxone o Closely monitor their respiratory status b/c of shorter half-life, effects can ware off faster Benzodiazep...