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68C Ph2 Test 3
Pre, Intra, Post Pt. Care, Wound Mgt, Anti-Infective, Pain Meds
| Question | Answer |
|---|---|
| Anesthesia | means the absence of feelings (pain), (an, meaning "without," and esthesia, meaning "awareness of feeling"). May be divided into three categories: general, regional, and local. |
| Embolus | a thrombus that becomes dislodged and travels through the blood stream |
| Infarct | localized area of necrosis caused by inadequate blood supply. |
| Informed consent | permission obtained from the patient to perform a specific test or procedure. |
| Intraoperative | during surgery |
| Perioperative | a term used to describe the entire term of the surgery, including what occurs before, during and after the operation. |
| Preoperative | begins with the decision to perform surgery and continues until the client has reached the operating area. |
| Thrombus | an accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the anterior wall of the vessel. |
| Which laboratory and diagnostic studies should be reviewed Preoperatively? | mplete blood count. Blood type and crossmatch. Serum electrolytes. Urinalysis. Chest x-ray. Electrocardiogram. Other tests PT, PTT, BUN, creatinine, and other radiographic studies. |
| Preoperative Assessment | Client assessment. Review preoperative instructions, diet restrictions and skin preparations. If client has not followed instructions, notify physician immediately |
| When surgery is not urgent, a more thorough history and physical are performed | Review preoperative laboratory and diagnostic studies. Review the client’s health history and preparation for surgery. Assess physical needs. Assess psychological needs. Assess cultural needs |
| If client has not followed preop instructions what should you do? | Notify physician immediately |
| Fluctuate rapidly during surgery do to anasthesia | Potassium (K+) Levels |
| Pre-Oprative teaching of Post Operative exercises should be done how long before the Surgery. | Ideally pre-operative teaching is done 1 to 2 days prior to surgery |
| During Pre-Operative Patient Care the LPN Teaches that Turning Improves? | venous return. respiratory function. gastrointestinal peristalsis |
| During Pre-Operative Patient Care the LPN Instructs Proper techniques for? | Leg position, Use of side rails, Splinting, Frequency |
| Coughing Exercises are important part of pre-operative Patient Care because | Post-Operative, Coughing Facilitates the removal of retained mucus from the respiratory tract |
| Usually is taught in conjunction with deep breathing? | Coughing because deep breathing before coughing, helps stimulate cough reflex |
| for Pre-Operative Patient Care for Coughing the the patient should be instructed in? | Proper positioning. Splinting |
| What Rate should a patient perform deep breathing exercises post-operatively | 5-10 times every hour during the postoperative period |
| Deep breathing exercises are important Pre-Operatively because they? | Helps expand collapsed lungs and prevent postoperative pneumonia and atelectasis |
| During patient teaching, after the LPN demonstrates they should ask the patient to perform what check on learning? | Have patient return demonstration |
| An incentive spirometer used to? | encourage deep breathing & prevent atelectasis |
| At what rate should a Post-Operative patient perform Incentive Spirometry? | 10 times during each waking hour for the first 5 days after surgery (except immediately before or after meals) |
| During Pre-Operative Patient Care you should teach the Patient that leg exercises will be important post-operative because? | They can help prevent; circulatory problems, such as thrombophlebitis or thrombus formation and gas pains |
| Leg exercises should be repeated at what rate post-operativley | Repeat the exercises every 1 to 2 hours |
| The LPN will teach the Pre-Operative patient that early Ambulation after the surgery is important because? | walking Helps the patient breathe deeply, Stimulates circulation, Urine retention, Constipation, Abdominal distention, Appetite, Sleep, Helps the patient feel less helpless. |
| atelectasis | Collapsed Lung |
| The LPN knows Pain Management is an Area of major concern for the patient and family, so they teach the patient | Pain is a normal part of the surgical experience, and Pain Mangement interventions will be ordered by the physician and administered by the nurse. |
| Post-Operative Pain medications are usually ordered on? | (PRN) As needed basis |
| Pre-Operatively during patient teaching the LPN should teach that the Patient should request pain medication when? | before the pain is severe |
| When will oral medictions be administered for post-oprative pain management? | can be used once the patient is able to eat and pain levels have decreased |
| What Route are pain mangement medications administered immediately post-operative? | They are Usually given by injection for the first few days. |
| Homan’s Sign | pain in the calf with dorsiflexion of the foot, indicating thrombophlebitis or thrombosis. |
| Anti-embolism Stockings | Tight-fitting hosiery prescribed by a physician Commonly used to help prevent deep vein thrombosis, edema, and leg Ulcers. They work by preventing the pooling of blood in the lower extremities |
| When the LPN performs the Pre-Operative Assessment they notice; Pigmentation around the Ankles, pitting Edema, Peripheral cyanosis, and Holmam's sign. What intervention is indicated? | Use of Anti-Embolism Stockings |
| How is the patient positioned to put on Anti-Embolism Stockings? | Stocking should be applied while the patient is in the supine position. |
| Sequential compression devices (SCD) | utilize sleeves with separated areas or pockets of inflation, which works to squeeze on the appendage in a “milking action.” The most distal areas will initially inflate, and the subsequent pockets will follow in the same manner |
| preferred prophylaxis in neurosurgery for the prevention of DVT and pulmonary embolism? | Sequential calf compression and graduated compression stockings |
| Intraoperative SCD-therapy is recommended during prolonged? | laparoscopic surgery to counter altered venous blood return from the lower extremities and consequent cardiac depression caused by pneumoperitoneum (inflation of the abdomen with carbon dioxide).[ |
| To apply Sequential Compression Devices the LPN will? | Place sleeve under patient's leg with fuller portion at top. Ensure there are no wrinkles or creases. Fold Velcro strips over to secure stockings. Attach tubing to SCD after both sleeves are applied |
| How should th epatient be positioned when using an incentive spirometer? | sitting upright with head of bed elevated 45 degrees |
| The patient should be instructed to do what before inserting the mouthpiece of an incentive Spirometer?. | take 2-3 normal breaths before insertion |
| Breathing technique to be used while using an incentive spirometer | Inhale through the mouth and hold their breath for 3-5 seconds. Exhale slowly and fully |
| Pre-Operative form that completion needs to be assured of? | SF 522, Request for Administration of Anesthesia and for Performance of Operations and other Procedures |
| Pre-Operative, the patient's chart is prepared? | using a surgical checklist/ preoperative checklist |
| Pre-Operative Gastrointestinal Preparation | NPO after midnight, A bowel cleanser may be ordered |
| Pre-Operative Skin Preparation | Shower and Hair removal |
| Pre-Operative The morning of surgery | Complete morning care, Visit with family, Record vital signs, Identification band is on the patient, Preoperative consent forms signed, medical records are in order. Recheck accuracy of surgical check list |
| A witness is attesting to patient's understanding the surgical risks? | No! The witness is witnessing the patient's signature |
| Administer preoperative medication, if ordered. Provide for patient's security. Assist the OR tech to position patient on litter . “Sign out" patient in nurse's notes | Pre-Operative The morning of surgery |
| The nursing interventions in the immediate postoperative phase follows the ABC-CS | A-Airway, B-Breathing, C-Circulation, C-Consciousness, S-System Review |
| Sitting upslightly with pillow behind shoulders | Supine Rescue Position |
| Lateral resuce Position | Position on side with face down and neck slightly extended |
| Airway management Immediate Post-Operative | Note presence or absence of gag/swallow reflex; stay at bedside until gag reflex returns. Suction until awake and alert. Provide oxygen if necessary, and have suction ready!. |
| Post Anesthesia Care (B - Breathing) | Evaluate depth, rate, rhythm, & chest movement. Mucous membranes. Coughing and deep breathing exercises. Chart time oxygen is discontinued. Oxygen saturation levels (Sa02) |
| Post Anesthesia Care (C-Circulation) | Monitor T, P, R, and B/P every 10 to 15 min. Assess pulse. Evaluate skin and nail beds. Peripheral pulses as indicated. Incision/dressing. Monitor wound drainage output. IVs: solution, rate, and site. Cardiac monitors |
| Discharge from the PACU is dependent on? | full return of consciousness, and normal VS and temperature. |
| Monitor VS, during Post Anesthesia Patient Care every? | 15 minutes until the patient is discharged which is usually at least 1 hour (monitoring is based on PACU policy). |
| extubate | (the process of removing endotracheal tube from airway). |
| Post Anesthesia Patient Care (C – Consciousness) | Able to extubate. Patient responds to commands. Verbalizes responses. Reacts to stimuli |
| Post Anesthesia Patient Care (S – System Review) | Neurological functions. Drains and tubes. Dressings. Pain. Allergic reaction. Urinary output |
| System Review | A review of body systems identifies when body functions return and provides a guideline for further assessments. |
| During Post Anesthesia Care observe the dressing for? | Check the type and condition of dressings. Mark any drainage that is on the dressing when you receive the patient so you can continue to assess. |
| During Post Anesthesia Care if pain is Observed the nurse may? | may need to give analgesic and monitor patient response. |
| How often are vital signs checked in the post-anesthesia care unit (PACU)? | Minimum every 15 minutes |
| Spinal anesthesia is used for? | Lower abdominal. Pelvic procedures. Lower extremity procedures. Urology procedures. Surgical obstetrics |
| Spinal anesthesia: | Lumbar puncture introduces local anesthetic. Patient's n influences movement of the anesthetic. Anesthesia can extend from the tip of the xiphoid process down to the feet. |
| used for lower abdominal, pelvic, and lower extremity procedures; urology procedures, or surgical obstetrics | Spinal anesthesia |
| Spinal anesthesia risks | Migration (Drug, Amount, Patient position) Vasodilation/ decrease in BP, Respiratory paralysis |
| Migration of anesthetic depends on? | the drug, amount of drug, and patient position |
| Spinal Anesthesia block to sympathetic vasomotor nerves and pain and motor nerve fibers. What VS will be affected | There may be a sudden decrease in blood pressure, which results from extensive vasodilation |
| When spinal Anesthesia is being used, If the level of anesthesia rises? | respiratory paralysis may develop , requiring resuscitation by the anesthesiologist |
| Elevation of the upper body prevents? | respiratory paralysis. |
| What vital signs are most important to monitor in the recovery of a patient with spinal anesthesia? | Respiratory rate and blood pressure |
| Spinal anesthesia nursing care | Monitor the vital signs q 3 to 5 minutes until patients is stable. Level of consciousness. Level of anesthesia. Physical assessment. Proper position |
| Post Anesthesia Patient Care, Check the patient's level of consciousness making sure? | There is no loss of memory of the surgical procedure and no loss of gag reflex. |
| Post Anesthesia Patient Care, Check the patient's level of anesthesia on the body to assure? | it is not going above the diaphragm. |
| Post Anesthesia Patient Care, Check for burns or other trauma on the patient, as the patient will not? | be aware of pain in the anesthetized parts of the body. |
| Post Anesthesia Patient Care, The staff must use caution regarding topics of discussion because? | the patient may not be sedated. |
| Post Anesthesia Patient Care, the staff has to be careful no to? | gain a false sense of security because of the patient's relative alertness. |
| Laryngospasm | secondary to the airway becoming irritated and the smooth muscle of the laryngx spasm. These patients will need to be sedated and reintubated if the spasm can’t be stopped. |
| Malignant hyperthermia | related to a genetic disorder that is trigger by certain anesthesia agents. This causes the person the spike a very high temperature (103 and above), muscle rigidity and this is a life threatening reaction to anesthesia |
| Patients often complaints of being cold after surgery are often related to. | Patients often complain of being cold after surgery |
| Post Anesthesia Patient Care, Potential postoperative complications | Nausea and vomiting. Aspiration. Hypothermia / Hyperthermia. Laryngospasm. Hypoxia. Hemorrhage. Pain. Hypovolemic shock. Decreased / absent urine output. Increase / Decrease IV input |
| Keep HOB at 45 degree angle to? | prevent aspiration |
| Post Anesthesia Patient Care, often the first complaint? | Pain |
| Patients complaints of being cold after surgery | Often a warm blanket placed around the feet resolves this issue? |
| Why would a Decrease urine output would be an unexpected finding following surgery? | If you have IV’s infusing you should have the proper amount of urine being made? |
| Documentation of Postoperative Phase Assessment, This is important to do every 15 minutes because? | the patient's status can change rapidly during this time. |
| Nursing management to prevent postoperative respiratory problems include? | Early mobility and frequent position changes. Deep breathing and coughing exercises. Use of incentive spirometer |
| contraindicated in patient's with ICP? | Coughing because it increases intracranial pressure |
| Although internal organs do not have many nerve endings, a skin incision does? | produce painful responses. |
| Acute pain begins to subside | 24 to 48 hours after surgery. |
| Recovery Period: | begins when the patient arrives in the hospital room or a postsurgical unit and extends until after discharge from the hospital and full activity is resumed. |
| postoperative patient | a patient, who has any type of surgical procedure performed |
| The length of time a patient needs to recuperate from a surgical experience depends on? | Physical and mental preparation. Type and magnitude of the surgical procedure |
| Later Postoperative Period, Nurse administered narcotic analgesia | Ask every 3 to 4 hours if something for pain is needed. Some patients won’t ask. Do not allow pain to become severe (More difficult to manage) |
| Patient controlled analgesia (PCA) | predetermined amount of analgesic contained within the unit; the system is programmed to allow only a specified amount of analgesic to be dispensed. |
| The PCA unit should be monitored closely every? | 3 to 4 hours |
| The length of time a patient needs to recuperate from a surgical experience depends on? | Physical and mental preparation. Type and magnitude of the surgical procedure |
| The Postoperative Patient, The major goals of nursing management are | prevention and detection of complications. Prevent injury. Regain independence. Patient education |
| Dehiscense: | the rupture of wound closure. |
| Evisceration | The internal organs protrude through the incision. |
| May occur 3 days to 2 weeks post-op? | Evisceration |
| If an Evisceration presents? | Contact the physician immediately. Cover the wound with sterile towel moistened with warm sterile saline. |
| Later Postoperative Period, Incision Care | Observe for drainage-reinforce if necessary, Dressings are not usually changed for 24 hrs post op |
| Accurate measurement of drainage | Circle drainage & mark time and date on dressing |
| The Postoperative Patient, Pain medication should be timed in relation to? | Activities, such as dressing changes or ambulation |
| 15 | Because a surgical patient's condition may change rapidly during the immediate postoperative recovery, the nurse should monitor the patient's status at least every______ minutes |
| Pulmonary embolism | Obstruction of one or more arterioles originating in the venous system |
| Signs and Symptoms of Pulmonary Embolism | Sharp, stabbing chest pain. Cyanosis. Anxiety. Profuse diaphoresis. Rapid, irregular pulse. Dyspnea, tachypnea |
| Nursing interventions for pulmonary embolism | Administer O2. Have patient sit in an upright position. Reassure and comfort patient. Monitor vital signs, EKG, and ABGs. Administer analgesics as ordered. Initiation of thrombolytic therapy. Notify charge nurse STAT |
| Pneumonia: | Inflammation of the alveoli as a result of an infectious process or foreign material. |
| Pneumonia can occur as a result of the following | Aspiration. Infection. Depressed cough reflex. Dehydration. Immobilization. Increased secretions from anesthesia |
| Signs and Symptoms of Pneumonia | Elevated temperature, Chills, Crackles or wheezes on auscultation, Dyspnea, Chest pain, Productive cough |
| Position to facilitate lung expansion of a patient with Pneumonia | Semi-Fowler's |
| Whenever air exchange is reduced or compromised, postoperative recovery? | Slows. Medication, suction, and oxygen therapy may be needed to assist the patient in respiratory distress |
| If the patient’s respiratory status doesn’t improve the MD may consider a Respiratory Therapy consult, who can provide? | Intermittent Positive Pressure Breathing, chest physiotherapy or chest percussion, and postural drainage to help dislodge and remove secretions |
| Nursing Concerns and Interventions - Respiratory | Semi-Fowler's. Administer O2 as ordered. Maintain nutritional and fluid status. Encourage turning, coughing, and deep breathing. Frequent oral hygiene. Teach proper disposal of tissue and sputum. Provide for rest and comfort. Provide emotional support |
| Nursing Concerns and Interventions - Comfort - Nausea and vomiting | Maintain clean environment. Provide frequent oral hygiene. Encourage sips of liquids at frequent intervals. Administer medications as ordered |
| Because the patient’s have been NPO for many hours prior to surgery, you should introduce fluids and food? | slowly to prevent nausea. Encourage ice chips, then sips of fluids, then something more. You are reassessing with each increase in oral intake. |
| Hiccups after surgery can be a sign of? | abdominal distention usually related to gas in the intestinal tract, but can also be related to internal bleeding. |
| pressure point which helps with getting rid of hiccups. | Gentle pressure on your pupils with your eyes closed |
| Medications that are used for hiccups that don’t resolve on their own | Thorazine, Compazine, and Reglan |
| To help decrease discomfort in the incisional area when coughing? | apply a splint directly over the lower abdomen |
| Nursing Concerns and Interventions - Elimination. Assessment | Assess for the return of peristalsis. Monitor input and output. Maintain IV fluids as ordered. Encourage PO fluids as ordered and tolerated. Provide privacy |
| Auscultate bowel sounds for? | one full minute every 4 hours while awake |
| Normal Assessment value, Bowel Sound Auscultation. | 5-30 gurgles per minute |
| When Ausculatating Bowel Sounds the nurse determines there is less 5 gurgle. What do thye suspect? | paralytic ileus |
| paralytic ileus | Obstruction of the intestine due to paralysis of the intestinal muscles. The paralysis does not need to be complete to cause ileus, but the intestinal muscles must be so inactive that it prevents the passage of food and leads to a functional blockage of t |
| Nursing Concerns and Interventions - Discharge | Keep the incision clean and dry. Follow all physician's recommendations. Contact the physician for: fever, chills, drainage from incision, foul odor or pus from incision, redness, streaking pain or tenderness. |
| List 4 possible comfort measures for the patient with nausea and vomiting. | Maintain clean environment. Provide frequent oral hygiene. Encourage sips of liquids at frequent intervals. Administer medications as ordered |
| Nursing Concerns and Interventions - Elimination | Assess for the return of peristalsis. Monitor input and output. Maintain IV fluids as ordered. Encourage PO fluids as ordered and tolerated. Provide privacy |
| Acute Pain-pain | sudden in onset, usually subsides when treated and typically occurs over less than a 6 week period. |
| Addiction | a primary, chronic, neurobiologic disease whose development is influenced by genetic, psychosocial and environmental factors. Also referred to as Psychologic Dependence. |
| Naloxone (Narcan) | Complete or partial reversal of narcotic depression, including respiratory depression. Capable of restoring respiratory function w/in 1-2 minutes. ***Narcan also removes all the pain relieving effects of the opioid |
| Naltrexone (ReVia) | Used with the PT addicted to opioids. Blocks the euphoric effects experienced in opiate dependency |
| Romazicon (Flumazenil) | reverses the effects of benzodiazapines such as Valium or Versed |
| Elimination | the process that removes drugs from the body |
| Half Life | the time required to reduce the concentration of a drug in the body by ½ |
| Amnesia | the inability to remember |
| Analgesia | inability to feel pain though conscious |
| Autonomic stability | stability of the autonomic nervous system, composed of the sympathetic and parasympathetic nervous system |
| Muscle relaxation | inability of the muscles to contract or maintain resting tone |
| General Anesthesia | A drug induced state in which the CNS nerve impulses are altered to reduce pain and other sensations throughout the entire body. It normally involves complete loss of consciousness and depression of normal respiratory drive. |
| Used for major procedures requiring extensive tissue manipulation | General Anesthesia |
| General Anesthesia Administered by | Inhalation agents and/or IV anesthetics |
| Induction phase of General Anesthesia | Agent administration/intubation |
| Maintenance phase of General Anesthesia | Positioning, skin prep, surgery |
| Emergence phase of General Anesthesia | Anesthetic decrease, awakenin |
| Malignant Hyperthermia signs | rapid rise in body temp, tachycardia, tachypnea & muscle rigidity (uncontrolled skeletal contractions triggered by certain anesthetics) |
| Malignant Hyperthermia | potentially fatal, inherited disorder usually associated with the administration of certain general anesthetics and/or the drug succinylcholine. The disorder is due to an acceleration of metabolism in skeletal muscle. |
| Malignant Hyperthermia interventions | Cool quickly and monitor for dysrhythmias |
| Local or Regional Anesthesia | Loss of sensation in a specific area of the body. No loss of consciousness. Usually the patient is sedated |
| A significant complication from spinal anesthesia is? | Headache, to provide relief Encourage the patient during post-op evaluation to drink plenty of fluid to replace leaked CSF |
| Spinal Anesthesia | Deeper Central Anesthesia – LP introduces to subarachnoid space, can extend from xiphoid to feet |
| Epidural Anesthesia | More superficial Central Anesthesia - LP to epidural space, blocks sensation in vaginal/perineal region |
| Commonly used during labor and delivery for pain management | Epidural Anesthesia |
| Peripheral Anesthesia | Local Anesthesia - Anesthetic is delivered in close proximity to nerves in order to interrupt impulse conduction. Sedation is usually used for patient comfort (anxiolysis |
| Nerve Block | Local anesthetic into nerve (brachial plexus to block arm) Anesthetic solution is injected at the site where a nerve innervates a specific area . Affects only a very specific area |
| Infiltration Anesthesia | Local anesthetic usually used for Suture and Dental procedures. Injected into the tissue that surrounds the operative area. Often used with agents that cause constriction of local blood vessels (lidocaine with epinephrine) |
| Topical Anesthesia | Local anesthetic applied directly onto the surface of the skin, eye or mucous membrane to relieve pain. Commonly used for diagnostic eye exams and skin suturing |
| Lanacane, Solarcaine (sunburn), EMLA (numbing cream) | Topical Anesthesias |
| Moderate (Conscious) Sedation | Does not necessarily cause complete loss of consciousness & minimizes risk of respiratory arrest. allows for relaxation, reduction of anxiety, and allows the patient to respond verbally and maintain own airway |
| Clinical uses for Moderate (Conscious) Sedation | Procedures such as burn dressing changes, colonoscopy and bronchoscopy. Preoperative sedation. Quick recovery; requires close monitoring |
| Commonly used agents for Moderate/Conscious Sedation | Benzodiazepines, Opiods, Anesthetics - Propofol “Milk of Amnesia” |
| Monitoring Moderate Sedation, Pre-procedure | Identify baseline information/risk factors |
| Monitoring Moderate Sedation, During procedure | Continuous monitoring by a RN. Immediate access to a crash cart. 68C may assist in data collection |
| Monitoring Moderate Sedation, Post-procedure | Assessment & discharge instructions |
| Monitoring Moderate Sedation, Documentation | Interventions, patient response and patient teaching performed |
| Anticholinesterases (neostigmine, pyridostigmine) | Reverse effects of neuromuscular blocking agents (vecuronium for RSI) by increasing neurotransmitters available at the neuromuscular junction. Inhibit acetylcholinesterase to provide greater use of ACh |
| Surgeon | Responsible for performing the surgery in a safe and effective manner. Leader of the surgical team |
| Anesthesiologist | a physician trained in the administration of anesthetics or |
| Anesthetist (CRNA) | A RN trained in the administration of anesthetics |
| Scrub Nurse | Arranges sterile supplies/instruments. Checks for proper functioning. Counts sponges, needles & instruments w/ circulating nurse prior to procedure /prior to wound closure. Gowns and gloves surgeons as they enter OR. Assists with surgical draping of PT |
| Circulating Nurse | Prepares operating room supplies. Ensures that equipment is functional. Arranges sterile and non-sterile supplies for scrub nurse. Sends for patient at proper time. Visits with patient preoperatively. Explains role, verifies operative permit, identifies p |
| Risk Factors & Complications of Surgery | Infection - Catheters, drains, surgical wound, Burns, Hypothermia, Hyperthermia, Bleeding/Hemorrhage, Pressures sores. Trauma injuries |
| What type of sedation is routinely used for procedures that do not require complete anesthesia but rather a depressed level of consciousness? | Conscious sedation |
| Antibiotics | Having or pertaining to the ability to destroy or interfere with the development of a living organism |
| Having or pertaining to the ability to destroy or interfere with the development of a living organism | Identify the organism. Obtain baseline labs. Assess for any allergies. Ability to administer around the clock. Ability to administer for entire therapy |
| Gram Stain, Gram Positive | Stains purple, Thick cell wall, Outer capsule. Solution can easily penetrate cell wall |
| Gram Stain, Gram Negative | Stains red. Complex cell wall structure. More difficult to treat. Solution can’t penetrate cell wall |
| Lab Tests to Identify infectious bacterial organisms | Culture and sensitivity. Gram Stain |
| to maintain therapeutic drug levels? | Administer Antibiotics around the clock |
| When using antibiotic therapy it is important to? | Administer for full course of treatment even if feeling better |
| Antibiotic Patient Teaching, Report signs of super infection | Black, furry tongue. Vaginal itching or discharge. Loose or foul-smelling stool. Allergic reaction |
| Antibiotic Patient Teaching, Notify Healthcare Provider if | Fever and diarrhea develop, Symptoms don’t improve |
| Mechanism of Action for Antibiotics, Bactericidal | kills bacteria |
| Mechanism of Action for Antibiotics, Bacteriostatic | inhibits bacterial growth |
| having or pertaining to the ability to destroy or interfere with the development of a living organism | Antibiotic |
| a chemical that inhibits the growth and reproduction of microorganisms without necessarily killing them. | Antiseptic |
| antibiotics that kill bacteria | Bactericidal antibiotic |
| antibiotics that do not actually kill bacteria but inhibit their growth. | Bacteriostatic antibiotics |
| the establishment and growth of microorganisms on the skin, open wounds or mucous membranes or in secretions without causing adverse clinical signs or symptoms | Colonization |
| the administration of drugs based on known results of culture and sensitivity testing identifying the pathogen causing infection. | Definitive therapy |
| a chemical applied to nonliving objects to kill microorganisms. | Disinfectant |
| the administration of drug based on the practitioner’s judgment of the most likely causing pathogen | Empiric therapy |
| antibiotics taken before anticipated exposure in an effort to prevent the development of an infection. | Prophylactic antibiotic therapy |
| referring to antibiotic treatment that is ineffective. | Subtherapeutic |
| an infection resulting from overgrowth of an organism not susceptible to the antibiotic used. | Superinfection |
| drug interaction in which the bacterial killing effect of two antibiotics given together is greater than the sum of the individual effects of the same drugs given alone. | Synergistic effect |
| Sulfonamides | Bacteriostatic antibiotic-does not kill the bacteria but does inhibit growth. Have a broad spectrum antibacterial activity –acts on both gram positive and gram negative bacteria. |
| Sulfonamides Exaples | Bactrim, Septra |
| Penicillins (PCN) | Bactericidal antibiotic- kills the bacteria by inhibiting cell wall synthesis. 4 subgroups of PCN that can act on either gram positive or gram positive and gram negative bacteria. |
| Penicillins (PCN), exaples | Natural PCN—PCN G, PCN V. Penicillinase resistant—Nafcillin. Aminopenicillins-Ampicillin, Amoxicillin. Extended Spectrum--Piperacillin |
| Cephalosporins | Bactericidal antibiotic- kills the bacteria by interfering with cell wall synthesis. Have a broad spectrum antibacterial activity –effects on gram positive , gram negative bacteria and anaerobic bacteria will depend on the generation of Cephalosporins |
| Cephalosporins Examples | Cefazolin-Ancef, Kefzol. Ceftriaxone-Rocephin |
| Macrolides | Bacteriostatic antibiotic-does not kill the bacteria, does inhibit growth. Large concentrations have bactericidal properties. Has broad spectrum antibacterial activity especially effect bacterial species that reproduce inside host cells instead of in blo |
| Macrolide Examples | (Erythromycin- E-mycin, EES), (Clarithromycin- Biaxin), (Azithromycin—Zithromax) |
| Quinolones a.k.a Fluoroquinolones | Bactericidal antibiotic-kills bacteria by altering bacteria’s DNA . Have a broad spectrum antibacterial activity –acts on both gram negative and selected gram positive bacteria. |
| Quinolones Examples | (Ciprofloxacin-Cipro), (Levofloxacin- Levaquin) |
| Aminoglycosides | Bactericidal-kills bacteria by interfering with protein synthesis. Used for serious gram negative infections and specific gram positive cocci bacteria |
| Eliminated through the kidneys-Highly nephrotoxic and ototoxic. Use with extreme caution in patients with pre-existing renal impairment. | Aminoglycosides |
| Aminoglycosides, Highly nephrotoxic | will see urinary casts, proteinuria, increased BUN and serum creatinine. |
| Aminoglycosides, Ototoxic | hearing loss is not reversible and is dose dependant, dizziness, tinnitus, |
| Aminoglycosides Examples | (Amikacin-Amikin), (Gentamicin-Garamycin), (Tobramycin—Nebcin) |
| Tetracyclines | Bacteriostatic antibiotic- inhibit growth by interfering with protein synthesis. Have a broad spectrum antibacterial activity –acts on many resistant bacteria |
| Tetracyclines Contraindications | drug allergy, pregnant and nursing women and pediatric patients under the age of 8 due to tooth discoloration. |
| Eliminated through the kidneys and liver | Tetracyclines |
| Tetracyclines, Examples | (Demeclocycline-Declomycin), (Doxycycline-Doryx) |
| Antibiotics Eliminated through the kidneys | Sulfonamides, Penicillins (PCN), Cephalosporins, Quinolones, Aminoglycosides, |
| Antibiotics Eliminated through the Liver | Macrolides |
| Adjuvant analgesic drugs | drugs that are added as a second drug for combined therapy and may have additive or independent analgesic properties or both. |
| Agonist | a substance that binds to a receptor and causes a response. |
| Analgesics | medications that relieve pain without causing loss of consciousness |
| Antagonist | a drug that binds to a receptor and prevents (blocks) a response. |
| Narcotics | a legal term. Originally applied to drugs that produce insensibility or stupor. Currently used in clinical setting to refer to any medically used controlled substance. Falling out of favor-substituting the term Opioid. |
| Nonopioid analgesic | analgesics that are not classified as opioids |
| Non-steroidal anti-inflammatory drugs (NSAIDs | a large chemically diverse group of drugs that are analgesics and also possess anti-inflammatory and antipyretic |
| Opioid analgesics | synthetic drugs that bind to opiate receptors to relieve pain but are not derived from the opium plant |
| Synergistic effects | drug interactions in which the effect of a combination of two or more drugs with similar actions is greater that the sum of the individual effects of the same drugs given alone. Example 1 + 1 is greater than 2. |
| used for pain management especially when the pain is associated with an inflammatory conditions? | NSAIDs |
| NSAIDs, Mechanism of action | Blocks peripheral pain impulses by inhibiting the enzyme that is necessary for prostaglandin synthesis. |
| Salicylates | Aspirin |
| Acetic Acid derivatives | Clinioril, Toradol |
| COX 2 inhibitors | Celebrex |
| Enolic Acid derivatives | Mobic, Feldene |
| Propionic Acid derivatives | Ibuprofen, Naproxen |
| antipyretic effects | control fever |
| Codeine and Hydrocodone are most commonly used in cough suppressants because? | They Suppress the cough center in the Medulla |
| When a patient is being treated with analgesics they are Encouraged to turn, cough, and deep breathe every? | 2 hr to prevent atelectasis |
| When pre-operative medications are given the nurse must monitor the patient for adverse reactions/side effects to include? | signs of respiratory depression and ensure that oxygen and resuscitative equipment is immediately available |
| If preoperative medication is given, The nurse places the bed in a? | low position, raises the side rails and monitors the patient every 15-30 minutes until the patient leaves for surgery. |
| Terbinafine | Lamisil |
| Amphotericin B | Systemic antifungal drug of choice for many severe systemic fungal infections |
| Interferons | simulate the body’s immune system to kill the virus. |
| Acyclovir | used to treat Herpes viruses |
| Ribavirin (Virazole) | used to treat respiratory syncytial virus |
| During IV Administration of Anti-Virals increase fluids to? | 3 liters per day to decrease crystalluria |
| antivirals and antiretrovirals do not? | prevent transmission to others. Precautions should be taken to prevent spread of virus |
| organism that lives in or on another organism without contributing to the survival or well being of the host. | Parasite |
| invasion of the body by worms (helminthes). | Helminthiasis |
| infectious disease caused by a protozoan and transmitted to humans through the bite of an infected mosquito | Malaria |
| invasion of the body by an amoeba. | Amoebiasis |
| Chloroquine if given with anti-seizure medications will? | result in the loss of seizure control |
| Mefloquine if given with Beta-blockers, calcium channel blockers or quinidine will? | increase the risk of dysrhythmias, seizures and cardiac arrest. |
| Primaquine if give with other hemolytic drugs will? | increase risk for myelotoxic effects (muscle weakness |
| Abrasions | a wound in which the surface layers of the skin are scraped away causing tissue loss in the epidermis and possibly the dermis. |
| Avulsion | wounds in which a portion of tissue is completely separated from its base and is either lost or left with a narrow base of attachment (a flap). |
| Closed Wounds | physical injury involving the underlying tissue of the body with the top layer of the remaining intact or not broken. |
| Contusion | injuries that do not break the skin Injury to soft tissue underlying the skins from the force of contact with a hard object; called a bruise. |
| Ecchymosis | discoloration of the skin, called a bruise. |
| Incisions | smoothly divided wounds made by a sharp instrument. |
| Infection | The invasions and multiplication of infective agents in body. |
| Lacerations | wounds caused by shear forces that produce a tear in tissues. The separation of skin and tissue can be irregular or sharp. |
| Open Wound | physical injury to body tissue with openings or breaks in the skin. |
| Punctures | wounds with a small opening and whose depth cannot be entirely Visualized; caused by a narrow, sharp or pointed object. A puncture wound can force dirt and microorganisms deep into tissue. Patients will usually require a tetanus booster. |
| Hemostasis | termination of bleeding, clot begins to form, usually with in minutes to hours after initial injury |
| Platelets adhere to the walls of the injured vessel. Fibrin in the clot will hold the wound together and stop the bleeding. | Hemostasis, clot formation |
| Inflammatory | initial increase in blood elements antibodies, electrolytes, plasma proteins and water flow out of the blood vessel and into the vascular space. |
| heat, redness, swelling, pain and tissue dysfunction. Leukocytes engulf bacteria, fungi, viruses, and toxic proteins. New cells form. Blood clot dissolves the wound fills. Sides usually meet in 24-48 hrs. Seals the wound and protects it. | Inflammatory Phase |
| Reconstruction | collagen formation occurs, usually from the 3-4th day to 2-3 weeks after initial injury |
| Fibroblasts produce collagen, which adds tensile strength. glue-like protein. Collagen increases rapidly, post-op days 5-25. Irregular raised purplish immature scar. Foods high in vitamins A and C help. Dehiscence occurs during this phase. | Reconstruction Phase |
| Maturation | from the 3rd week up to 2 years after the initial injury. Wound gains strength, scar formation, may develop a keloid (over growth of collagenous tissue) or hypertrophic scarring during this phase. |
| Wounds heal at varying speeds. Internal wounds heal faster than external wounds. Keloids are elevated, rounded and firm; color ranges from red to pink to white. | Maturation Phase |
| Primary intention | Wound edges are directly next to one another. Little tissue loss. Minimal scarring. Most surgical wounds heal by primary intention. Wound closure is performed with sutures, staples, or adhesive at the time of initial evaluation. |
| Granulation | tissue and capillaries must extend from the edges inside the wound toward the center, this results in a broader scar |
| Secondary intention | Epithelialization. Surgeon may pack a wound with gauze or use a drainage system to remove exudate. Granulation. Healing process is slow and can be prolonged. Wound care daily done daily. |
| Tertiary Intention (Delayed primary closure) | The wound is initially cleaned, debrided and observed for a period of time (typically 4 or 5 days) before closure. The wound is purposely left open by placing dressing material in the wound to keep the edges apart. |
| when does the nursing staff Assess the condition of wounds & dressing? | Every Shift |
| Wound care documentation | Location. Size (length x width x depth). Drainage type and amount. Odor. Neurovascular (NV) status. Peripheral vascular status: depending on site of injury. |
| Wound healing evaluation measures | Assess condition of the wound and dressing. Ask whether patient notes any discomfort during dressing change procedure; use pain scale to quantify level of pain. Inspect condition of dressings at least every shift. |
| Potential nursing diagnoses for a patient requiring wound care | Potential for infection related to alteration in skin integrity. Alteration in comfort related to injury. Knowledge deficit related wound care |
| What are the three types of wound healing? | Primary Intention. Secondary Intention. Tertiary (Delayed Primary) Intention |
| Abscess | cavity containing pus and surrounded by inflamed tissue, formed as a result of pus from a localized infection |
| Adhesion | band of scar tissue that binds together two anatomical surfaces normally separated; most commonly found in the abdomen |
| Cellulitis | infection of the skin characterized by heat, pain, redness, and edema. |
| Dehiscence | separation of a surgical incision or rupture of a wound closure |
| Extravasations | passage or escape into the tissues; usually of blood, serum, or lymph. |
| Hematoma | collection of extravasated blood trapped in the tissue or in an organ resulting from incomplete hemostasis after surgery. |
| Wound bleeding may indicate? | a slipped suture, dislodged clot, coagulation problem, or trauma placed on blood vessels or tissue. |
| Inspection of the wound and dressing aids in? | detecting an increase in drainage and color changes. |
| S/S of Internal Bleeding | Patient will have increase thirst, restlessness, rapid, thready pulse, decreased blood pressure, decreased urinary output, and cool, clammy skin. |
| Dressing may remain dry while the abdominal cavity collects blood. Abdomen will become rigid and distended. If not detected, hypovolemic shock can cause circulatory system collapse, causing death. | Internal Bleeding |
| S/S of Dehiscence | Patient may say that something has "given way". May result after periods of sneezing, coughing, or vomiting. Evidence of new or increased serosanguineous drainage on the dressing is an important sign to assess. |
| Dehiscence Management | Patient should remain in bed. Kept NPO. Told not to cough. Reassure patient. Place sterile dressing over area until physician evaluates the site. |
| Evisceration Management | Patient is to remain in bed. Wound and contents should be covered up with warm, sterile saline dressings. Surgeon is notified immediately - this is a medical emergency. |
| CDC labels: a wound is infected When? | it contains purulent (pus) drainage |
| Purulent drainage has? | foul odor and is brown, yellow or green, depending on the pathogen |
| Patient with an infected wound displays? | a fever, tenderness and pain at the wound site, edema, and an elevated WBC. |
| Wound Infection management | Topical and systemic treatment ordered per pathogen and clinical symptoms. |
| Factors that Impair Wound Healing | Extent of the Injury. Type of Injury. Age. Nutritional Status. Obesity. Impaired Oxygenation. Smoking. Drugs. Diabetes Mellitus. Radiation. Wound Stress |
| Which wound complication is a surgical emergency? | Evisceration, notify surgeon immediately |
| Surgical wounds generally heal better because? | they are aseptically created. They are usually covered by a dressing. |
| Gauze | permits air (with impurities) to reach wound |
| Semi-occlusive dressings | Permits oxygen but not air impurities to reach wound |
| Occlusive dressings | does not allow air or oxygen |
| thought to promote healing by keeping the wound moist yet sterile | Semi and Occlusive dressings |
| What may be used to secure dressings? | Tape ties, bandages or cloth binders |
| Inceision Dressing removal | Consult physician and agency policy. Medicate 30 min. prior if pain is expected. Assemble equipment needed. Sterile technique or standard precautions. Be careful not to disturb drains |
| When are Dressings over closed wounds are usually removed? | by the third day |
| Indication to use a dry dressing | Used when little exudate. Not used to debride a wound |
| Indication to use wet to dry dressings | Need for increased absorption of exudate. dressing adheres to wound |
| Wounds which call for Wet to dry Dressings | Abdominal evisceration, Dehiscence, Infected open wounds, Pressure ulcers, Diabetic foot ulcers |
| What supplies do you need to do a dry sterile dressing change? | Gloves, gauze, tape, basin, NSS or SW, 30-60 ml syringe, pad |
| Deep sutures are? | usually absorbable |
| Sutures | threads of wire or other material composed of Silk, cotton, linen, nylon, Dacron or metal |
| Suture techniques | Interrupted, separate, continuous, or blanket |
| Retention sutures | Covered with rubber tubing. Provide greater strength. Often used in obese patients. Do not have good cosmetic effect Left in place Usually 14 days or more |
| Staples | Made of stainless steel wire. Quick to use. Provide ample strength. Used when the appearance of the incision is not critical |
| When are Sutures and Staples usually removed | Generally within 7 to 10 days |
| What happens if sutures are are left in over 10 days? | removal more difficult and risk for infection |
| If there is any sign of line separation when removing sutures? | the remaining sutures or staples are left in place and the physician is notified. |
| Suture removal requires a? | physicians order. |
| Suture removal technique | One at a time. Every other suture or staple. Replace remove suture or staple with Steri-Strip. Then remove remaining sutures or staples if ordered. Sometimes remaining sutures or staples are left in place longer. |
| Exudate | fluid that has penetrated from blood vessels into surrounding tissues as the result of inflammation. |
| Drain | a device used to remove excess fluid from a wound or body part |
| Serous | clear, watery drainage that has been separated from its solid elements (e.g. exudate of a blister) |
| Sanguineous | drainage that contains blood. |
| Serosanguineous | drainage that contains serum and blood. |
| Purulent | drainage that contains pus. |
| Abnormal Wound Exudate/Drainage | greater than 300 ml in the first 24 hours is abnormal |
| If sanguineous drainage continues? | small blood vessels may be oozing |
| Considering Wound Drainage what may happen when the patient first ambulates? | slight increase in drainage may occur |
| Color, Amount, Odor | characteristics that are important to note and chart in wound documentation |
| Techniques used to Monitor wound Drainage | Weigh soiled dressings. Circle and date drainage area on dressings as necessary. Report number and type of dressings used |
| Open drains | Drainage passes through an open-ended tube into a receptacle or out onto the dressing |
| Penrose drain | soft tube that drains by gravity and may be advanced or pulled out in stages as the wound heals from the inside out. |
| Closed drains are more effective than open drains because? | they pull fluid by creating a vacuum or negative pressure |
| Closed/Suction Drains | Self-contained suction units. More effective than open drains. Creating a vacuum or negative pressure. Prevents environmental contaminants |
| Jackson-Pratt drain | used when small amounts (100-200 ml) of drainage anticipated |
| Hemovac drainage system | used for larger amounts (up to 500 ml) of drainage |
| Give two examples of a closed drainage system? | Jackson-Pratt and Hemovac |
| To evaluate wound healing the wound should be checked after? | Application of heat and cold therapies. Wound Irrigation. Stress to the wound site |
| The Wound should be checked after? | Each Dressing Change |
| Wound Evaluation Measures | Assess condition of the wound and dressing. Discomfort during dressing change. Inspect condition of dressings at least every shift |
| Keloids | elevated, rounded and firm; color ranges from red to pink to white |
| Staffing during sedation/analgesia must consists of? | minimum of one provider and one qualified nurse or technician. One person must be devoted to monitoring the patient |
| Only ___________ and ____________ with specialized training may administer conscious (moderate) sedation drugs | Physician's and Registered Nurses |
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