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Med Surg Jersey Coll
Exam 1 brunners ch 1.9.10
| Term | Definition |
|---|---|
| Moral Dilema | Two or more ethically pausible principles are in opposition to each other and only one may be chosen. |
| Moral distress | internal response that occurs when a health care provider believes they inherently know the correct ethical action but cannot act on that knowledge |
| Health | State of complete physical mental and social well being. |
| Wellness | Being equivalent to health |
| Algorithms | Used in acute situations |
| Guidelines and maps | Most detailed, used in education and d/c |
| QSEN | Curricula for education that includes interdisciplinary core competences, including, patient centered care, interdisciplinary teamwork, and collaboration. |
| Complex issues in nursing | Greater acuity of pts in hospitals and community, aging population, complex disease process, end of life concerns ethical issues and cultural factors. |
| Critical thinking includes | Purposeful, Insightful, reflective, goal directed. |
| Metacognition | The examination of ones own reasoning, or thought process- to help refine thinking skills. |
| Critical thinkers are: | Users of habits of the mind including, confidence, perseverance, inquisitiveness, intuition, flexibility, creativity, intellectual integrity, contextual perspective, open mindness, and contextual perspective. |
| Bracketing | Objective and not personal |
| The Nursing Process | Assessment, Diagnosis, Planning, Implementation, Evaluation. |
| Mucomist | Antagonist for tylenol |
| Nonopiod | Acetaminophen, NSAIDS: Ibuprofen, Naproxen, Celecoxib |
| Opiod | Mu agonist: Morphine, hydromorphone, fentanyl, oxy. Agonist- Antagonist: buprenorphine, nalbuphine, burtophanol. |
| hepatoxic | Tylenol |
| nephrotoxic | NSAIDS |
| NANDA | Official organization responsible for autonomy for nursing diagnosis. |
| Collaborative problems | Managed in a group with other healthcare providers/ Provider |
| Parts of planning | Setting priorities, stablish expected outcomes, goals, determining nursing actions. |
| Adjunctive analgesics | local anesthetics, anticonvulsants, antidrepressants, ketamine |
| Local | lidocaine 5% |
| anticonvulsants | gaba and pregablin |
| antidepressants | TCAs desipramine, nortryptiline, amitryptiline SNRIS duloxitine, venlaxafine |
| Ketamine | Horse tranquilizer/ peds/ reductions/ casting |
| Ethics | Formal systematic study of moral beliefs to understand, analyze and evaluate matters of right and wrong |
| Morality | Includes specific values, characters, or actions whose outcomes are often examined through systematic ethical analysis |
| Double effect | Principal that may morally justify some actions that produce both goods and evil effects. 1. The action itself is good 2. Agent sincerely y intends the good and not evil effect 3.The good effect is not achieved by means of the evil effect 4. There |
| Distributive justice | Everyone obtains the same care |
| physical independence to opioids | Can happen with use with 2 weeks |
| Tolerance | Normal response with regular use of opioids Decrease in one or more of the effects Increase usage needed to effect pain relief |
| Utilitarianism | Greatest good for the greatest number |
| Deontologic or formalist theory | Argues that ethical standards or principals exist independently of the ends of the consequences |
| Gerontologic Considerations for pain meds | Higher sensitivity to agents of sedation and CNS effects, Initiate with low doses and tritrate, high risk for NSAID induce gi toxicity Acetaminophen preferred for mild pain Opioid dose should be reduced to 50% No more than 3 grams for tylenol |
| Colloid | Fluid containing particles that are non soluble and evenly distributed through out the solution |
| Typical adult fluid percentage | 60% Varies with fat, age, gender |
| Intracellular fluid | Fluid in cells/ 2/3 of body fluid, skeletal muscle mass. 40% body weight |
| Extracellular | Intravascular: Blood vessels Interstitial ,: Sorrounds the cell and totals about 11-12 L includes lymph Trancellular space: smallest division, CSF, pericardial,synovial, intraocular, and pleural fluids, sweat and digestive digestion. 1 L |
| Cations | Positive electrolytes: Sodium, potassium, calcium, magnesium, hydrogen ions |
| Anions | Negative electrolytes: Chloride, bicarbonate, phosphate, sulfate. |
| Colloid oncotic pressure | Osmotic pressure created by the protein ( mainly albumin) in the bloodstream |
| Crystaloid | Fluid containing soluble mineral ions and water in solution |
| Hydrostatic pressure | Pressure created by the weight of fluid against the wall that contains it, in the body hydrostatic pressure in blood vessels results from the weight of fluid itself and the force resulting from cardiac contraction |
| Osmosis | Movement of water to make all concentrations equal |
| Solvents | ETOH, Fat, H2o,plasma |
| Solutes | Na + , K+ , CL- |
| Direction of fluid movement | Depends on differences of hydrostatic pressure and osmotic pressure |
| Hypertonic solution | Solution with with an osmolality higher than serum/ 3,5,10 |
| Hypotonic solution | Solution with an osmolality lower than that of serum |
| Isotonic solution | Same osmolality of blood, 0.9% NaCl same as the bloodstream and water concentration as the bloodstream. Do not provoke movement between ICF and ECF Expand the plasma volume of the blood |
| Tonicity | Fluid tension or the effect that osmotic pressure of a solution with impemeable solutes exerts on cells size because of water movement across the cell membrane |
| Fluid goes in | Osmotic pressure has to be higher than hydrostatic |
| Fluid goes out | Hydrostatic higher than osmotic |
| Diffusion | Solutes move from area of higher concentration to one of lower concentration |
| Filtration | Movement of water and solutes from area of high hydrostatic pressure to area of low hydrostatic pressure |
| Active transport | Sodium-Potassium pump/ Maintains higher concentration of extracellular sodium , intracellular potassium |
| Homeostatic mechanisms | Kidney, Heart and blood vessels, Lung, Pituitary gland, Adrenal, Parathyroid, Baroceptors |
| Blood cell components | Erythrocytes, leukocytes, platelets |
| Plasma components | 92% water, solvent, that contains solutes including proteins ( albumin) glucose, lipoproteins, and mineral ions, termed electrolytes |
| Contents of fluid | Lowest water content: Skeleton Highest: Muscle, skin, and blood. |
| Third space fluid | Accumulates within membrane- bound spaces, such as the peritoneal, pleural space. ex: ascites. pleural effusion, pericardial effusion, angioedema. Evidence by decrease in urine output despite fluid intake Increased hr, decresed b/p, decresed central ven |
| Milliequivalent | Defined as being equivalent to the electrochemical activity of 1 mg of hydrogen |
| Retention of sodium | Associated with fluid retention |
| Loss of sodium | Decreased volume of body fluid |
| Major electrolyte in ECF | Sodium |
| Major electrolyte in ICF | Pottasium |
| Changes of potassium within the ECF | Can cause cardiac rhythm disturbances, and hyperkalemia |
| Fluid Volume Deficit | May occur alone or in combination, loss of extracellular fluid caused by vomiting and diarrhea excessive sweating, GI suctioning Nausea, decrease access to fluids third space fluid shift, diabetes insipidus adrenal insufficiency, hemorrhage. |
| Sodium | 135-145 outside cell/ 10-14 inside cell Meq/L |
| Pottasium | 3.5-5.0 outside cell/ 140-150 inside cell Meq/L |
| Chloride | 98-106 outside cell/ 3-4 inside cell |
| Bicarb | 24-31 outside / 7-10 inside |
| Calcium | 8.8-10.5- outside/ <1,Meq/L Inside |
| Phosphorus | 2.5-4.5 - outside/ variable |
| Magnesium | 1.8-3.6 outside/ 40 Meq / Kg b |
| Starlings Law of Capillary Forces | Capillary forces at every capillary membrane: Hydrostatic pressure and Osmotic pressure |
| Oncotic Pressure | Pressure exerted by the albumin within the bloodstream =termed oncotic pressure or colloid osmotic pressure |
| Crystalloids | Mineral Ions dissolved in water, Such as Normal Saline 0.9% NaCl Hypo- Half Normal Saline 0.45% NaCl and lactated rings solution Commonly used to replace fluids in Hypovolemia |
| Colloid | Albumin solutions, hyper oncotic starch, and dextran. Commonly used as temporary blood replacement until available blood product. |
| Hypotonic solutions | Less sodium chloride than the blood 0.45, 0.225, used to move fluids from ECF into ICF Usually used to hydrate patients. Never given with ICP |
| Hypertonic solutions | Greater concentration of Sodium chloride compared to blood. 3% 5% 10% Used to pull water from the ICF into the ECF, Causes dehydration of cells. Used for severe edema, cerebral edema |
| Toxicity of Lasix | Ototoxic |
| Osmotic diuresis | Increase in urine output caused by the excretion of solutes, such as glucose or manitol. These solutes exert a force that pulls water out of the ICF into the ECF to be excreted by the kidneys |
| General rule of urine output | 1 ml per kg of body weght per hour |
| Chief solutes in sweat | Sodium, chloride and pottasium |
| insensible water loss by lungs | 500/ml day |
| Urine osmolarity is determined by | Urea, creatnine, uric acid |
| Urine specific gravity | 1.005-1.030 Measures the density of urine compared to water |
| Serum osmolality | reflects the concentration of sodium |
| BUN | Value that measures the amount of urea in the bloodstream. 10-20 mg/dl . Reflects scretion of nitrogen and urea |
| Factors that increase BUN | GI bleed, sepsis, fever. |
| Factors that decrease BUN | End stage liver disease, low protein, starvation expanded fluid volume |
| Creatnine | breakdown product of muscle metabolism that is totally cleared from the bloodstream and excreted by the kidney . Better indicator of renal function because it does not vary with protein intake or hydration status 0.7-1.4 mg/dl |
| Increases in serum creatnine | occurs with renal function decrease. Accurate gauge of kidney function. |
| Hematocrit | measure of the percentage of rbc in a volume of whole blood . Ranges from 42-52% in men and 35-47% in woman. |
| Causes for increase in hematocrit | dehydration and polycythemia. |
| Causes for decrease in hematocrit | Over hydration and anemia |
| Normal sodium urine levels | 75-200meq/24h |
| Kidney function | Regulation of fluid and electrolyte balance, filters 180 L of plasma daily. Excretes about 1-2 L of urine. Act autonomously and by hormones, ADH and aldosterone |
| Heart and vessels | Circulation of blood |
| Lung functions | Assist by insensible loss of water, and acid- base regulation |
| Pitiutary functions | The hypothalamus manufactures ADH, released by the posterior pituitary gland to act on the nephrons at the collecting ducts to increase reabsorption of water. |
| Adrenal functions | Aldosterone, secreted by the zona glumerulosa of the adrenal cortex, Increases secretion of aldosterone causing sodium retention for water retention, and potassium loss |
| Parathyroid functions | regulates calcium and phosphate balance by means of the parathyroid hormone PTH wich cause sreavsorption of calciym fromt he bones into the bloodstream, calcium absorption from the intestine, and calcium reabsorption into the blood stream from the renal t |
| RAS | Kidneys sense low perfussin or low BP Renin is secreted by kidneys in the juxtaglomerular apparatus RAS Triggers Renin circulates to Liver to convert angotensinogen into angiontensin 1 ACE converst angio 1 to angio 2 wich than stimulates peripheral a |
| Anti Diuretic hormone | As serum concentration and osmolarity increases, or blood volume decreases, neurons in the hypothalamus are stimulated by intracellular dehydration than thirst happens. ADH its also released to increase BP and reduce urine output |
| osmoreceptors | on the hypothalamus, sense sodium concentrations, if osmotic pressure increases, post pity releases ADH for sodium and h2o retention in kidney |
| Natruietic peptides | Hormones that control cadiovascula function through natrurisis ( excretion of sodium) vasodialtion, and opposition of RAS |
| Types of Natriuretic peptides | Atrial: Synthetized, stored and release from muscles of atria of heart Brain: Ventricular muscle of heart N terminal of Pro brain: Ventricular muscle of heart/ use in diagnosis of HF |
| Other causes for secretion of Natriuretic peptides | Renal failure, Coronary heart disease, valvular heart disease, constrictive pericarditis, pulmonary hypertension, and sepsis. |
| Decreased renal function in geriatrics | Causes high creatnine cause by decreased renal function |
| Decreased muscle mass in geriatrics | Causes low serum creatnine |
| Symptoms of fluid deficit in geriatrics | May evidenced by by delirium instead of thirst |
| Fluid volume deficit | ECF volume loss exceeds the intake of fluid. Ration of water to electrolyte may remain the same. FVD may occur alone or in combination |
| Dehydration | Loss of water with increased sodium levels |
| Patho of FVD | May be caused by vomitting, diarreah, GI suction, sweating, third space fluid shift, diabetes insipidus, deficit of ADH, osmotic diuresis, hemorrhage and coma. |
| Assesments and labs for FVD | BUN to derum creatnine concentration ratio: 10:1 Abnormal may show as 20: 1 due to urea concentration high hematocrit, aletered pottasium and sodium |
| hypokalemia with FVD | GI and renal losses since these organs are major regulators of pottasium |
| hyperkalemia | Adrenal insuffenciency, due to alodosterone deficiency causing lack of pottasium excretion |
| Hyponatremia | Increased thirst and ADH release, increasing water content in blood |
| hypernatremia | Increase insensible water loss and diabetes insipidus |
| Oliguria | urine less than 400 ,ml |
| Reaction of water concentration in the kidneys | high osmolarity ti 45 mosm along with specific gravity |
| Signs and symptoms of DFV | Oliguria, weight loss, low turgor, low BP, flattened neck veins, dizzinws, weakness, high pulse, cramps, sunken eyes, high temp, clammy pale skin, |
| Signs and Symptoms of FVE ( hypervolomia) | Acute weight gain, edema, ascites, distended JV, crackles, Elevated CVP , sob, high bp, bounding hr, cough, high rr, low hemo and hema, low serum and osmolality, low urine sodium and specif gravity |
| 0.9% NaCl Isotonic Normal Saline | Expands extracellular fluid, used for hypovolemia, resusitation, shock, DKA, metabolic alkalosis, hypercalcemia, When mixed with 5% dextrose it becomes temp hypertonic, provides 170cal/l Only solution to be used with blood products tonicity like plasma |
| Lactated Ringers solution/ Isotonic/ aproximate to electrolyte concentration as body but lacks magnesium/ not to be given with kidney injury, due to K+ that may hyperkalemia | Provides 9cal/l , used for hypovolemia, burns, fluid lost as bile or diarrhea, acute blood loss, Metabolizes to HCO3 so it should not be used with lactic acidosis due to HCO3 convetion. Not given with PH less than 7.5, Risk for alkalosis, |
| 5% dextrose in water ( Dw5)/ Isotonic? 170cal/l , contains free water to aid in renal excretion, /converts to hypotonic as dextrose is metabolized /risk for water intoxication | Used for hypernatremia, fluid loss, dehydration, Not to be used in excess the early post op period due to ADH oversecretion due to stress, Not to be used as only in VFD due to dilution of plasma and electro, No for head injury, may cause ICP, may cause hi |
| 0.45% NaCl ( half strength) Hypotonic/ contains free water, 170cal/L | Used for hypertonic dehydration, Na- CL depletion, gastric fluid loss, Not indicated for third space fluid shift, or increased intracranial pressure, Need to given slow due to risk of fluid shift from vascular to cells resulting in cardio collapse and ICP |
| 3%, 5%, IV Mannitol 5-25% Hypertonics | Used to Increase ECF volume and decrease cellular swelling, critical treatment of hyponatremia. Given slow due to risk of intravascular volume overload, and pulmonary edema. Supplies no calories. |
| Colloid solutions/ Dextran in NS or D5W / low molecular weight (Dextran 40) And High ( Dextran 70) | Used as plasma expander for ECF intravascular, Affects clotting by coating platelets and decreasing ability to clot, Remains in system for 24h. Treats hypovolemia in early shock to increase pulse press, cardiac output, ABP . Contraindicated in hemorrahge |
| Prerenal azotemia | reduced renal blood flow secondary to FVD |
| Intrarenal azotemia | Acute tubular necrosis |
| Fluid challenge test | To asses renal function |
| Nursing management in FVD | Asses I and os every 8h to 1h Monitor VS closely |
| Tongue turgor | More reliable than skin turgor since not affected by age |
| preventing hypovolemia | minimize fluid loss, administered antidiarreahl, antiametic, and offer fluids in small amounts |
| Correcting hypovolemia | Small amounts of fluid and mouth care, Rehydrate, Elete, Cyto. |
| saline levels with Hypervolemia | Sodium and Water levels remain same in proportions |
| Hypervolemia Patho | Overload or diminished function of fluid regulating , contribuiting may be HF, Kydney dysfunction, cirrhosis, consuption of high salt. |
| Clinical Manifestations of Hypervolemia | Edema in the ankles, sacrum |
| Labs for Hypervolemia | Low Hematocrit, and BUN due to plasma dilution, chest xray to check for fluids in lungs, Urine sodium normal because of aldosterone. |
| Medical management of hypovolemia | Diuretics and sodium restrictions |
| Mild to moderate Hypervolemia treatment | Thiazide diuretics, like Hydrochlorothiazide to remove 5%-10%, from reapsorption blockage at the distal tubule. |
| Severe treatment of Hypervolemia treatment | Loop diuretics such as furesomide, bumetadine and torsemide. reabsorbs 20-30% water and sodium athe ascending loop oh henley. |
| Side effects of diuretics | Hypokalemia can occur with all diuretics except those that inhibited aldosterone |
| Azotemia | Increased Nitrogen in the blood |
| Nutritional therapy for Hypervolemia | Sodium restrictions from 2000 to 250 mg, drinking distilled water if softeners or other sources of salt in water, if malnourishment is present, protein high intake recommended for oncotic pressure. |
| Nursing Interventions of hypervomia, | Check for edema in most dependent parts of body, breath sounds for those given parental fluids. |
| SIADH | Caused by overproduction of ADH also called arginine vasopressin, May be caused by brain surgery, brain tummor, pulmanary malignancy, aids and mechanical ventilalion |
| Agonist | medication that binds to an opiod receptor mimicking the way endogenous substances provide analgesia |
| Agonist Antagonist | type of opioid (e.g., nalbuphine and butorphanol) that binds to the kappa opioid receptor site acting as an agonist (capable of producing analgesia) and simultaneously to the mu opioid receptor site acting as an antagonist (reversing mu agonist effects) |
| allodynia: | pain due to a stimulus that does not normally provoke pain, such as touch; typically experienced in the skin around areas affected by nerve injury and commonly seen with many neuropathic pain syndromes |
| antagonist: | a medication that competes with agonists for opioid receptor binding sites; can displace agonists, thereby inhibiting their action |
| breakthrough pain: | a transitory increase in pain that occurs in the context of otherwise controlled persistent pain |
| central sensitization | key central mechanism of neuropathic pain; the abnormal hyperexcitability of central neurons in the spinal cord, which results from complex changes induced by the incoming afferent barrages of nociceptors and results in an increased nociceptive neuron res |
| comfort–function goal | the pain rating identified by the individual patient above which the patient experiences interference with function and quality of life (e.g., activities the patient needs or wishes to perform) |
| half-life | time it takes for the plasma concentration (amount of medication in the body) to be reduced by 50% (after starting a medication, or increasing its dose; |
| hyperalgesia | an increasingly intense experience of pain resulting from a noxious stimulus |
| metabolite | the product of biochemical reactions during medication metabolism |
| multimodal analgesia or multimodal pain management | intentional, concurrent use of more than one pharmacologic or nonpharmacologic intervention with different methods of action with the goal to achieve better analgesia while using lower doses of medications with fewer adverse effects |
| neuropathic (pathophysiologic) pain | pain caused by injury or dysfunction (lesion or disease) of one or more nerves of the peripheral or central nervous systems with resultant impaired processing of sensory input |
| nociceptive (physiologic) pain | pain that is sustained by ongoing activation of the sensory system that conducts the perception of noxious stimuli; implies the existence of damage to somatic or visceral tissues sufficient to activate the nociceptive system |
| nociceptor: | type of primary afferent neuron that has the ability to respond to a noxious stimulus or to a stimulus that would be noxious if prolonged |
| opioid dose–sparing effect | occurs when a nonopioid or co-analgesic medication is prescribed in addition to an opioid, enabling the opioid dose to be lower without diminishing analgesic effects |
| opioid-induced hyperalgesia | phenomenon in which exposure to an opioid induces increased sensitivity, or a lowered threshold, to the neural activity conducting pain perception; it is the “flip side” of tolerance |
| peripheral sensitization | peripheral mechanism of neuropathic pain that occurs when there are changes in the number and location of ion channels; in particular, sodium channels abnormally accumulate in injured nociceptors, producing a lower nerve depolarization threshold, |
| preemptive analgesic agents | pre-injury pain treatments (e.g., preoperative epidural analgesia and preincision local anesthetic infiltration) to prevent the development of peripheral and central sensitization of pain |
| refractory | nonresponsive or resistant to therapeutic interventions such as analgesic agents |
| Nociceptive Pain | Normal processing of stimuli that damages tissues or has the potential to do so if prolonged; can be somatic or visceral |
| Neuropathic Pain | Abnormal processing of sensory input by the peripheral or central nervous system or both |
| Types of pain rating scales | Numeric Rating Scale , Wong–Baker FACES, FaceVerbal descriptor scale s Pain Scale, Visual Analogue Scale |
| Description of pain | Quality, Onset and duration, Aggravating and relieving factors, Effect of of pain on quality of life |
| Flacc | For use in young childeren , assessing Facial expression, Leg movement, Activity, Crying, and Consolability, with each of these five categories assigned scores from 0 to 2, yielding a total composite score of 0 to 10. |
| PAINAD | indicated for use in adults with advanced dementia who are not able to verbalize their needs. |
| CPOT | indicated for use in patients in critical-care units who cannot self-report pain, |
| Pain after reassessment after parental administration medication | 15-30 minutes |
| Pain reassessment after oral administration of pain medication | 1-2 hours |
| Morphine | Standard opiod, used for cancer pain, first med to be given intraspinally, first line for long term intraspinal analgesia, only opiod t produce analgeia for up to 48 hours following epidural adm. Hydrophillic, It may produce nerotoxicity. |
| Fentanyl | LIpophilic, fast onset and short duration of action, commonly used for rapid IV analgesia desired, such as for scalating acute pain and short procedures.Prefered for organ failing patient, due to no metabolites. Patch for long term care. |
| Hydromorphone | hydrophillic and hydropholic/ in between/ Second choice after morphine, may be use via IV PCA |
| Oxycodone | Oral only, for all types of pain, may be used as multimodal treatment for post op pain. |
| Oxymorphone | Take on empty stomach / avoid alcohol due to increase concentration. |
| Hydrocodone | Available only in combination with nonopioids with acetaminophen or ibuprofen. Most common prescribed for persisiten pain, |
| Methadone | Synthetic, muopiod, second to third line drug for neupathic pain. |
| Equianalgesia | means approximately “equal analgesia.” An equianalgesic chart provides a list of doses of analgesic agents, both oral and parenteral (IV, subcutaneous, and intramuscular), that are approximately equal to each other in ability to provide pain relief. |
| Recommended dosing for acetaminophe | 1000 mg every 6 hours for a maximum of 4000 mg in adult patients |
| Dual-Mechanism Analgesic Agents | tramadol and tapentadol bind weakly to the mu opioid receptor site and block the reuptake (resorption) of the inhibitory neurotransmitters serotonin and norepinephrine at central synapses in the spinal cord and brain stem of the modulatory descending pain |
| Tramadol | used for both acute and chronic pain and is available in oral short-acting and modified-release formulations, including a short-acting tablet in combination with acetaminophen. neuropathic pain, lower seizure threshold |
| Tapentado | is available in short-acting and modified-release oral formulations. This medication has been shown to produce dose-dependent analgesia comparable to oxycodone. Major benefits are that it has no active metabolites |
| Opioids to Avoid | Codeine is a prodrug, Meperidine has either been removed from or severely restricted |
| Adverse Effects of Opioid Analgesic Agents | common adverse effects of opioids are constipation, nausea, vomiting, pruritus, hypotension, and sedation. Respiratory depression, while less common, is the most serious and feared of the opioid adverse effects |
| Adverse Effects of Opioid Analgesic Agents/ increased agents | such as benzodiazepines (e.g., diazepam), alcohol, and barbiturates |
| Adverse Effects of Opioid Analgesic Agents | surgical patients, postoperative ileus can become a major complication |
| Morphine lowers blood pressure | dilating peripheral arterioles and veins. In the presence of dehydration or with concomitant use of hypotensive medications, orthostatic hypotension may result |
| Long-term use of opioids | may result in opioid-induced androgen deficiency and sleep disordered breathing |
| Postoperative nausea and vomiting (PONV) | occur following opioid administration due to medulla chemoreceptor trigger zone stimulation |
| three major classes of opioid receptor sites involved in analgesia | mu, delta, and kappa. |
| . Prevention of clinically significant opioid-induced respiratory depression | administration of the lowest effective opioid dose, careful titration, close monitoring of sedation and respiratory function and status (i.e., rate, depth, regularity, excursion) throughout therapy, and prompt dose reduction when advancing sedation is det |
| Pasero Opioid-Induced Sedation Scale with Interventions | S = Sleep, easy to arouse, 1 = Awake and alert, 2 = Slightly drowsy, easily aroused. Acceptable; no action necessary; may increase opioid dose if needed |
| Pasero Opioid-Induced Sedation Scale with Interventions 3 = Frequently drowsy, arousable, drifts off to sleep during conversation | Unacceptable; monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory; decrease opioid dose 25–50%1 or notify primary2 or anesthesia provider for orders; administering a no |
| Pasero/4 = Somnolent, minimal, or no response to verbal and physical stimulation | stop opioid; consider administering naloxone3,4; call Rapid Response Team (Code Blue); stay with patient, stimulate, and support respiration as indicated by patient status; notify primary2 or anesthesia provider; monitor respiratory status and sedation le |
| For adults experiencing respiratory depression | mix 0.4 mg of naloxone and 10 mL of normal saline in syringe and administer this dilute solution very slowly (0.5 mL over 2 min) while observing the patient’s response (titrate to effect). |
| Hospital protocols should include the expectation that a nurse will administer | naloxone to any patient suspected of having life-threatening opioid-induced sedation and respiratory depression. |
| comprehensive respiratory assessment for opiod induced resp deprssion | proper assessment requires watching the rise and fall of the patient’s chest to determine rate, depth, and regularity of respirations. Listening to the sound of the patient’s respirations is critical as well—snoring indicates airway obstruction and must |
| opioid antagonist naloxone is promptly given IV | to reverse clinically significant opioid-induced respiratory depression |
| Primary adverse effects of TCAs , antidepressants | dry mouth, sedation, dizziness, mental clouding, weight gain, and constipation. Orthostatic hypotension is a potentially serious TCA adverse effect. The most serious adverse effect is cardiotoxicity |
| Ketamine | dissociative anesthetic with dose-dependent analgesic, sedative, and amnestic properties At high doses, this medication can produce psychomimetic effects (e.g., hallucinations, dreamlike feelings); does not produce respiratory depression. |
| Nonpharmacologic Methods of Pain Management | Physical modalities, Cognitive and behavioral methods, Movement therapy, Biologically based therapies, Energy therapies |
| Fentanyl patch time effectiveness after 1st patch | 12-18 hours |
| Fentanyl levels that remain after patch removal | 16 hours |
| Restrictions with lithium | Hyponatremia |
| Fluid therapy for hypernatremia | Half chloride, Electrolytes. |
| Alkalosis K+ shift | K+ will move into cells until alkalosis is resolved. |
| Too much aldosterone | May cause addison disease and hypokalemia |
| Hypokalemia ECG | Dysrhythmias, ST depression, prominent U waves. |
| Hypokalemia | Give hypertonic fluids slow, don't fry her brain. |
| Hyponatremia clinical manifestations | Poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping can occur. |
| Neurologic changes in hyponatremia | mental status, status epilepticus, and coma, are related to the cellular swelling and cerebral edema associated with hyponatremia. |
| Chronic decreases in sodium, developing over 48 hours or more, | can occur in status epilepticus and other neurologic conditions |
| Acidosis my cause | Hyperkalemia |
| nursing management for hyperkalemia | Monitor ECG, apical pulse, BP, labs, Iand Os , Limit K+ in diet. Administer cation xchage ion sodium plysterine sulfonate) |
| Emergent care for hyperK+ | IV calcium gluconate, iV bicarb, IV regular insulin and hypertonic dextrose IV, Beta 2 agonist dialysis... Insulin assists potassium to transport into the cell. |
| when hyponatremia is due to SIADH | urinary sodium content is greater than 20 mEq/L, and the urine specific gravity is usually greater than 1.012. Although the patient with SIADH retains water abnormally there is no peripheral edema; instead, fluid accumulates inside the cells. |
| Serum sodium must not be increased by | No more than 12 mEq/L in 24 hours to avoid neurologic damage due to demyelination |
| In SIADH, the administration of hypertonic saline solution alone cannot change the plasma sodium concentration. | Excess sodium would be excreted rapidly in highly concentrated urine. With the addition of the diuretic furosemide, urine is not concentrated and isotonic urine is excreted to effect a change in water balance. |
| AVP receptor antagonists (also called ADH receptor antagonists) | pharmacologic agents that treat hyponatremia by blocking the effect of ADH at the nephron, which in turn allows diuresis to occur and leads to water excretion. |
| The small amount of calcium located outside the bone circulates in the serum, | partly bound to protein and partly ionized. Calcium plays a major role in transmitting nerve impulses and helps regulate muscle contraction and relaxation, including cardiac muscle. |
| Calcium is instrumental in activating enzymes that stimulate many essential chemical reactions in the body | and it also plays a role in blood coagulation |
| The normal adult total serum calcium level | 8.8 to 10.4 mg/dL |
| Calcium exists in plasma in three forms: | ionized, bound, and complex. |
| Calcium deficit (hypocalcemia) Serum calcium | Hypoparathyroidism , malabsorption, pancreatitis, alkalosis, vitamin D deficiency, massive subcutaneous infection, generalized peritonitis, massive transfusion of citrated blood, chronic diarrhea, decreased parathyroid hormone, diuretic phase of acute kid |
| Calcium deficit (hypocalcemia) | Numbness, tingling of fingers, toes, and circumoral region; positive Trousseau sign and Chvostek sign; seizures, carpopedal spasms, hyperactive deep tendon reflexes, irritability, bronchospasm, anxiety, |
| Calcium deficit (hypocalcemia) | impaired clotting time, ↓ prothrombin, diarrhea, ↓ BP. ECG: prolonged QT interval and lengthened ST Labs indicate: ↓ Mg++ |
| Calcium excess (hypercalcemia) Serum calcium >10.4 mg/dLmay be caused by corticosteroid therapy, thiazide diuretic use, increased parathyroid hormone, and digoxin toxicity | Hyperparathyroidism, malignant neoplastic disease, prolonged immobilization, overuse of calcium supplements, vitamin D excess, oliguric phase of acute kidney injury acidosis, |
| Calcium excess (hypercalcemia Muscular weakness, constipation, anorexia, nausea and vomiting, polyuria and polydipsia, dehydration, hypoactive deep tendon reflexes, | lethargy, deep bone pain, pathologic fractures, flank pain, calcium stones, hypertension. ECG: shortened ST segment and QT interval, bradycardia, heart blocks |
| Calcium is absorbed from | foods in the presence of normal gastric acidity and vitamin D |
| The serum calcium level is controlled by | PTH and calcitonin |
| As ionized serum calcium decreases in the bloodstream, | parathyroid glands secrete PTH. This, in turn, increases calcium absorption from the GI tract, increases calcium reabsorption from the renal tubule, and releases calcium from the bone. |
| increase in calcium ion concentration in the bloodstream | suppresses PTH secretion. When calcium increases excessively, the thyroid gland secretes calcitonin, which inhibits calcium reabsorption from bone and decreases the serum calcium concentration |
| Hypocalcemia (serum calcium value lower than 8.8 mg/dL [2.20 mmol/L]) occurs in a variety of clinical situations. A patient may have a total-body calcium deficit (as in osteoporosis) | Older adults and those with disability have an increased risk of hypocalcemia because immobility, particularly lack of weight-bearing activity, increases bone resorption |
| Transient hypocalcemia can occur with | massive administration of citrated blood (i.e., massive hemorrhage and shock), because citrate can combine with ionized calcium and temporarily remove it from the circulation |
| Hypocalcemia is common in patients with acute kidney injury, | because these patients frequently have elevated serum phosphate levels. Hyperphosphatemia usually causes a reciprocal drop in the serum calcium level. |
| Other causes for hypocalcemia | inadequate vitamin D consumption, magnesium deficiency, medullary thyroid carcinoma, low serum albumin levels, alkalosis, and alcohol abuse. |
| Medications predisposing to hypocalcemia include | aluminum-containing antacids, aminoglycosides, caffeine, cisplatin, corticosteroids, mithramycin, phosphates, isoniazid, loop diuretics, and proton pump inhibitors |
| most characteristic manifestation of hypocalcemia and hypomagnesemia, Trousseau sign Chvostek sign twitching of muscles innervated by the facial nerve in response to tapping of the muscle just below the zygomatic arch. | Tetany: complex induced by increased neural excitability caused by spontaneous discharges of both sensory and motor fibers in peripheral nerves |
| Hypocalcemia can cause seizures | low calcium levels increase irritability of the central and peripheral nervous systems. |
| Other changes associated with hypocalcemia include mental changes such as depression, impaired memory, confusion, delirium, and hallucinations. | A prolonged QT interval is seen on the ECG due to prolongation of the ST segment, and torsades de pointes, a type of ventricular tachycardia |
| Respiratory effects with decreasing calcium | include dyspnea and laryngospasm. Signs and symptoms of chronic hypocalcemia include hyperactive bowel sounds, dry and brittle hair and nails, and abnormal clotting |
| When evaluating serum calcium levels | serum albumin level and the arterial pH must also be considered |
| Emergency Pharmacologic Therapy hypocalcemia | IV administration of a calcium salt. Parenteral calcium salts include calcium gluconate and calcium chloride |
| IV administration of calcium for hypocalcemia therapy warning | particularly dangerous in patients receiving digitalis-derived medications, because calcium ions exert an effect similar to that of digitalis and can cause digitalis toxicity, with adverse cardiac effects. |
| IV administration of calcium for hypocalcemia therapy warning | IV site that delivers calcium must be observed often for any infiltration because of the risk of extravasation and cellulitis or necrosis. Calcium replacement can cause orthostatic hypotension; therefore, the pt should remain in bed during IV infusion, |
| Quality and Safety Nursing Alert for hypocalcemia therapy | Too rapid IV administration of calcium can cause cardiac arrest, preceded by bradycardia. Therefore, calcium should be diluted in D5W and given as a slow IV bolus or a slow IV infusion using an infusion pump. A 0.9% sodium chloride solution should not be |
| Nutritional Therapy for hypocalcemia | Vitamin D therapy, to increase calcium absorption from the GI tract; aluminum hydroxide, calcium acetate, or calcium carbonate antacids may be prescribed to decrease elevated phosphorus levels before treating hypocalcemia in the patient with chronic kidne |
| dietary intake of calcium to treat hypocalcemia | at least 1000 to 1500 mg/day in the adult is recommended. Calcium supplements must be given in divided doses of no higher than 500 mg to promote calcium absorption. |
| Nursing Management in hypocalcemia | Seizure precautions are initiated if hypocalcemia is severe. The status of the airway is closely monitored because laryngospasm can occur |
| Hypercalcemia (serum calcium value greater than 10.4 mg/dL | malignancies and hyperparathyroidism. Malignant tumors can produce hypercalcemia by various mechanisms. breast, lung, renal, and multiple myeloma |
| Calcifications of soft tissue occur when | the calcium–phosphorus product (serum calcium × serum phosphorus) exceeds 70 mg/dL. Calcium levels are inversely related to phosphorus levels |
| calcium is lost | during immobilization, and sometimes this causes elevation of total (and especially ionized) calcium in the bloodstream. However, symptomatic hypercalcemia from immobilization is rare; when it does occur, it is limited to people with high calcium turnover |
| Thiazide diuretics | can cause a slight elevation in serum calcium levels because they potentiate the action of PTH on the kidneys, reducing urinary calcium excretion. |
| Vitamin A and D intoxication | as well as chronic lithium use and theophylline toxicity, can cause calcium excess. |
| Hypercalcemia reduces neuromuscular excitability because it suppresses activity at the myoneural junction. | Decreased tone in smooth and striated muscle may cause symptoms such as muscle weakness, incoordination, anorexia, and constipation. Lethal arrhythmias (e.g., ventricular fibrillation |
| Calcium enhances the inotropic effect of digitalis | therefore, hypercalcemia aggravates digitalis toxicity |
| Hypercalcemic crisis refers to an acute rise in the serum calcium level. Emergency treatment with calcitonin is indicated | Severe thirst and polyuria are often present. Other findings may include muscle weakness, intractable nausea, abdominal cramps, severe constipation, diarrhea, peptic ulcer symptoms, and bone pain. Lethargy, confusion, and coma may also occur. This conditi |
| Cardio changes in hypercalcemia | changes may include a variety of arrhythmias (e.g., heart blocks) and shortening of the QT interval and ST segment. The PR interval is sometimes prolonged. |
| pHarma for hyperkalemia | fluids 0.9% Sodium chloride to dilute Ca and excrete by kidney, restrict Ca intake, mobilize the pt, IV phosphate for inversion, Furesomide for excretion aid. Cacitonin for pts with heart disease |
| Action of calcitonin. / Derived from salmon / Check allergies/ given IM, intranasal. due to poor tissue perfusion in high Ca | Reduces bone resorption, deposition of Ca and phosph in the bones. and increases excretion of Ca in the urine. |
| Magnesium (Mg++) is an abundant intracellular cation 1.8 to 2.6 mg | It acts as an activator for many intracellular enzyme systems and plays a role in both carbohydrate and protein metabolism. |
| Magnesium balance is important | neuromuscular function. Because magnesium acts directly on the myoneural junction, high serum high mag: low excitability of muscle cells, deficit increases neuro muscular irritability and contractility. |
| Effects of magnesium if cardiovascular system | produces vasodilation and decrease peripheral resistance |
| Storage of mag | Most is stored in bones, magn ions are bound to protein such as albumin or free Mg Ions |
| Hypomagnesium less than 1.8 | Caused by alcoholism, hyperthyroid, hyperaldosterism, acute kid inj, DKA, starvation and reefeeding, parental nutrition, laxatives, caca, acute MI, HF, low K+, and Ca. gentamycing, cisplatin, cyclosporine |
| signs and symps of hypomagnesium | Trousseau sign, Chovstek, imnsomia, moody, anorexia, vomit, high tendon reflex, high BP, ECG: PVCS, flat orinverted T waves depressed ST, prolonged PR interval , wide QRS |
| Hypermagnesium > 2.6 mg | Oliguric pahse of KF , adrennal infufficiency, excess IV mag, DKA hypothyrodism |
| Signs and symptoms of hypomagnesium | Flushing, low BP, muscle weakness, drowsy, hypoactive reflexess, depressed resps, cardiac arrest and coma, diaphoreses, ECG: thacy, brady, prolonged PR interval and QRS peaked T waves |
| For every 1 L of blood loss | 3 l of sodium chloride is required. |
| REED. phlebitis | Redness, edema, erythema, drainage |
| malignant hyperthermia: | triggered by exposure to most anesthetic agents inducing a drastic and uncontrolled increase in skeletal muscle oxidative metabolism that can overwhelm the body’s capacity to supply oxygen, remove carbon dioxide, and regulate body temperature, |
| moderate sedation | previously referred to as conscious sedation, involves the use of sedation to depress the level of consciousness without altering the patient’s ability to maintain a patent airway and to respond to physical stimuli and verbal commands |
| monitored anesthesia care: | moderate sedation given by an anesthesiologist or CRNA |
| registered nurse first assistant: | member of the operating room team whose responsibilities may include handling tissue, providing exposure at the operative field, suturing, and maintaining hemostasis |
| restricted zone: | area in the operating room where scrub attire and surgical masks are required; includes operating room and sterile core areas |
| scrub role: | registered nurse, licensed practical nurse, or surgical technologist who scrubs and dons sterile surgical attire, prepares instruments and supplies, and hands instruments to the surgeon during the procedure |
| semirestricted zone: | area in the operating room where scrub attire is required; may include areas where surgical instruments are processed |
| sterile technique: | measures taken to maintain an area free from living microorganisms, including all spores |
| surgical asepsis: | absence of microorganisms in the surgical environment to reduce the risk of infection |
| Gerontologic risk in traoperative | delirium, hypothermia, positioning injury, deep vein thrombosis (DVT) formation, electrolyte imbalance, and circulatory compromise |
| Anesthetic agents risk for gerontologic | Lower doses of anesthetic agents are required in older adults due to decreased tissue elasticity (lung and cardiovascular systems) and reduced lean tissue mass. |
| Muslims and those of the Jewish faith may not wish to use | porcine-based products [heparin (porcine or bovine)]; |
| Buddhists may choose not to use | bovine products). |
| The circulating nurse | manages the OR and protects the patient’s safety and health by monitoring the activities of the surgical team, checking the OR conditions, and continually assessing the patient for signs of injury and implementing appropriate interventions. |
| circulating nurse is responsible for ensuring | that the second verification of the surgical procedure and site takes place and is documented |
| The Scrub Role | performs the activities of the scrub role, including performing hand hygiene; setting up the sterile equipment, tables, and sterile field; preparing sutures, ligatures, and special equipment |
| registered nurse first assistant | practices under the direct supervision of the surgeon. RNFA responsibilities may include handling tissue, providing exposure at the operative field, suturing, and maintaining hemostasis |
| P2, P3, or P4 | has a systemic disease that may or may not be related to the cause of surgery. |
| P1, P2, P3, P4, or P5 | requires emergency surgery, an E is added to the physical status designation (e.g., P1E, P2E). |
| P6 | refers to a patient who is brain dead and is undergoing surgery as an organ donor. |
| Environmental Controls | ventilation provides 15 air exchanges per hour, at least three of which are fresh air A room temperature of 20° to 24°C (68° to 73°F), humidity between 30% and 60%, and positive pressure relative to adjacent areas are maintained. |
| circulating nurses and unsterile items | contact only unsterile areas. |
| Movement around a sterile field must not cause contamination of the field | At least a 1-ft distance from the sterile field must be maintained to prevent inadvertent contamination. |
| associated hazards in the surgical environment | Faulty equipment, improper use of equipment, exposure to toxic substances, surgical plume (smoke generated by electrosurgical cautery), as well as infectious waste, cuts, needlestick injuries, and lasers |
| Exposure to Blood and Body Fluids Basic scrub attire worn by sterile “scrubbed-in” OR personnel include | double sterile gloves, eye protection, surgical mask, a sterile gown, and shoe covers. |
| general anesthesia | (inhalation, IV |
| regional anesthesia | epidural, spinal, and local conduction blocks) |
| moderate sedation | monitored anesthesia care [MAC]), and local anesthesia. |
| Stage I GA | Dizzines, ringing, agitation, concious but difficulty moving, noises are exagerated |
| Stage II/ pupils dialate high hr/ restriction may be needed | The excitement stage, characterized variously by struggling, shouting, talking, singing, laughing, or crying, is often avoided if IV anesthetic agents are given smoothly and quickly |
| Stage III GA/ RR reg, pulse normal, this state can be maintained for hours in different depths | Surgical anesthesia is reached by administration of anesthetic vapor or gas and supported by IV agents as necessary. The patient is unconscious and lies quietly on the table. The pupils are small but constrict when exposed to light. |
| Stage IV: GA | medullary depression. This stage is reached if too much anesthesia has been given. Respirations become shallow, the pulse is weak and thready, and the pupils become widely dilated and no longer constrict when exposed to light. Cyanosis develops and, witho |
| Halothane/ inhalation anesthetic agent | Not explosive or flammableInduction rapid and smoothUseful in almost every type of surgeryLow incidence of postoperative nausea and vomiting |
| Enflurane Inhalation | Rapid induction and recoveryPotent analgesic agentNot explosive or flammable |
| Isoflurane Inhalation | Rapid induction and recoveryMuscle relaxants are markedly potentiated |
| Sevofluranea Inhalation | Rapid induction and excretion; minimal side effects Coughing and laryngospasm; trigger for malignant hyperthermia |
| Desflurane Inhalation | Rapid induction and emergence; rare organ toxicity Respiratory irritation; trigger for malignant hyperthermia |
| Nitrous oxide (N2O) Inhalation (semiclosed method) | Induction and recovery rapidNonflammableUseful with oxygen for short proceduresUseful with other agents for all types of surgery Poor relaxantWeak anestheticMay produce |
| Oxygen (O2) Inhalation | Can increase O2 available to tissues High concentrations are hazardous |
| Alfentanil | Surgical analgesia in ambulatory patients Ultra–short-acting (5–10 min) analgesic agent; duration of action 0.5 h; bolus or infusion |
| Fentanyl | Surgical analgesia: epidural infusion for postoperative analgesia; add to SAB Good cardiovascular stability; duration of action 0.5 h |
| Morphine sulfate | Preoperative pain; premedication; postoperative pain Inexpensive; duration of action 4–5 h; euphoria; good cardiovascular stability |
| Remifentanil | IV infusion for surgical analgesia; small boluses for brief, intense pain Easily titrated; very short duration; good cardiovascular stability. |
| Sufentanil | Surgical analgesia Duration of action 0.5 h; prolonged analgesia exceptionally potent (5–10 times more than fentanyl); provides good stability in cardiovascular |
| Succinylcholine | Relax skeletal muscles for surgery and orthopedic manipulations; short procedures; intubation Short duration; rapid onset |
| Atracurium besylate | Intubation; maintenance of skeletal muscle relaxation No significant cardiovascular or cumulative effects; good with kidney injury |
| Cisatracurium besylate | besylate Intubation; maintenance of skeletal muscle relaxation |
| Mivacurium | Intubation; maintenance of skeletal muscle relaxation Short acting; rapid metabolism by plasma cholinesterase; used as bolus or infusion |
| Rocuronium | Intubation; maintenance of relaxation Rapid onset (dose dependent); elimination via kidney and liver |
| Vecuronium | Intubation; maintenance of relaxation No significant cardiovascular or cumulative effects; no histamine release |
| d-Tubocurarine | Adjunct to anesthesia; maintenance of relaxation — No known effect on consciousness, pain threshold, or cerebration; might cause histamine release and transient ganglionic blockade |
| Metocurine | Maintenance of relaxation Good cardiovascular stability Slight histamine release |
| Pancuronium | Maintenance of relaxation — May cause ↑ HR and ↑ BP |
| Diazepam | Amnesia; hypnotic; relieves anxiety; preoperative Good sedation Long acting |
| Etomidate | Induction of general anesthesia; indicated to supplement low-potency anesthetic agents Short-acting hypnotic; good cardiovascular stability; fast, smooth induction and recovery May cause brief period of apnea; pain with injection and myotonic |
| Ketamine | Hypnotic; anxiolytic; sedation; often used as adjunct to induction Excellent amnesia; water soluble (no pain with IV injection); short acting |
| Propofol | Induction and maintenance; sedation with regional anesthesia or MAC Rapid onset; awakening in 4–8 min; produces sedation/hypnosis rapidly (within 40 s) and smoothly with minimal excitation; decreases intraocular pressure and systemic vascular resistance; |
| Methohexital sodium | Induction; methohexital slows the activity of brain and nervous system Ultra–short-acting barbiturate May cause hiccups |
| Thiopental sodium I | Induction; stops seizures — May cause laryngospasm |
| ERAS pathways | are developed by multidisciplinary teams to optimize the recovery from surgery by reducing the patient’s stress response. |
| An anesthetic agent is not considered metabolized until | all three systems (motor, sensory, and autonomic) are no longer affected. |
| Lidocaine | Epidural, spinal, peripheral IV anesthesia, and local infiltration RapidLonger duration of action (compared with procaine)Free of local irritative effect |
| Bupivacaine | Epidural, spinal, peripheral IV anesthesia, and local infiltration Duration is 2–3 times longer than lidocaine |
| Tetracaine | Topical, infiltration, and nerve block Long acting, produces good relaxation Occasional allergic reaction >10 times as potent as procaine Procaine Local infiltration — Occasional |
| Peripheral Nerve Blocks | eripheral nerve blocks (PNBs) are used in conjunction with general or MAC anesthesia, or as a stand-alone method. Instead of a single nerve being targeted, a bundle of nerves is located via ultrasound and injected with an anesthetic, opioid, or steroid. |
| Local Anesthesia, is often given in combination with | epinephrine. Epinephrine constricts blood vessels, which prevents rapid absorption of the anesthetic agent and thus prolongs its local action and prevents seizures. |
| Local Anesthetic Systemic Toxicity (LAST) | potentially life-threatening event. LAST occurs when a bolus of LA is inadvertently injected into peripheral tissue or venous or arterial circulation during a PNB or spinal nerve block procedure and is rapidly absorbed into systemic circulation, resulting |
| Symptoms of LAST | Metallic taste Oral numbness Auditory changes Slurred speech Arrhythmias Seizure Respiratory arrest |
| Treatment of LAST | should focus on airway management. Hypoxemia and acidosis intensify the effects of LAST. The nurse calls for help and maintains the patient’s airway while administering 100% oxygen and confirming IV access IV infusion of lipid |
| hypothermia and is indicated by | ore body temperature that is lower than normal (36.6°C [98°F] or less). |
| Malignant hyperthermia | inherited muscle disorder that is chemically induced by anesthetic agents, triggered by myopathies, emotional stress, heatstroke, neuroleptic malignant syndrome, strenuous exercise exertion, and trauma. |
| Clinical manifestations of Malignant hypothermia | Tachycardia Sympathetic nervous stimulation also leads to ventricular arrhythmia, hypotension, decreased cardiac output, oliguria, and, later, cardiac arrest. Hypercapnia, an increase in carbon dioxide (CO2), may be an early respiratory sign. |
| Late sign of malignant hypothermia | The rise in temperature is actually a late sign that develops rapidly; body temperature can increase 1° to 2°C (2° to 4°F) every 5 minutes, and core body temperature can exceed 42°C (107°F) |
| medical magnagmet of malignant hypothermia | Use of dantrolene has lowered mortality rates to 10% in current practice ( |
| Nursing assessment of the intraoperative patient involves | obtaining data from the patient and the patient’s medical record to identify factors that can affect care. |
| Areas of nursing assesment for intraoperative | obtaining data from the patient and the patient’s medical record to identify factors that can affect care. |
| evisceration: | protrusion of organs through the surgical incision |
| phase I PACU: | area designated for care of surgical patients immediately after surgery and for patients whose condition warrants close monitoring |
| phase II PACU: | area designated for care of surgical patients who have been transferred from a phase I PACU because their condition no longer requires the close monitoring provided in a phase |
| postanesthesia care unit (PACU) | area where postoperative patients are monitored as they recover from anesthesia |
| second-intention healing: | method of healing in which wound edges are not surgically approximated and integumentary continuity is restored by the process known as granulation |
| The postoperative period extends from | the time the patient leaves the operating room (OR) until the last follow-up visit with the surgeon |
| Transferring the postoperative patient from the OR to the PACU | is the responsibility of the anesthesiologist or certified registered nurse anesthetist (CRNA) and other licensed members of the OR team. |
| Recovery criteria for post op | return to baseline cognitive function, the airway is clear, nausea and vomiting is controlled, and vital signs are stabilized. |
| Assessing the Patient post op | airway, level of consciousness, cardiac, respiratory, wound, and pain. The patient’s comorbidities and type of procedure will dictate additional assessments such as peripheral pulses, hemodynamics, and surgical drain placements |
| postanesthesia assessment scoring tool, | Aldrete score |
| he treatment of hypopharyngeal obstruction | tilting the head back and pushing forward on the angle of the lower jaw, as if to push the lower teeth in front of the upper teeth. This maneuver pulls the tongue forward and opens the air passages. |
| pharyngeal suction tip or a nasal catheter introduced into the nasopharynx or oropharynx | to a distance of 15 to 20 cm (6 to 8 inch). |
| To monitor cardiovascular stability in post op | nurse assesses the patient’s level of consciousness; vital signs; cardiac rhythm; skin temperature, color, and moisture; and urine output. The nurse also assesses the patency of all IV lines. |
| The primary cardiovascular complications seen in the PACU include | hypotension and shock, hemorrhage, hypertension, and arrhythmias. |
| Quality and Safety Nursing Alert for hypotension during post op care | Quality and Safety Nursing Alert |
| The classic signs of hypovolemic shock are | pallor; cool, moist skin; rapid breathing; cyanosis of the lips, gums, and tongue; rapid, weak, thready pulse; narrowing pulse pressure; low blood pressure; and concentrated urine |
| primary intervention for hypovolemic shock is | volume replacement, with an infusion of lactated Ringer solution, 0.9% sodium chloride solution, colloids, or blood component therapy |
| Hemorrhage | patient presents with hypotension; rapid, thready pulse; disorientation; restlessness; oliguria; and cold, pale skin. The early phase of shock will manifest in feelings of apprehension, decreased cardiac output, and vascular resistance |
| Time frames for hemorrhage | Primary: at time of surgery. Intermediate: During first few hours post op due to BP levels normalizing. Secondary: Post op, by suture slip, blood vessel not anastomosed, infection or eroded by drainage tube. |
| Type of vessels in hemorrhage | Capillary: slow general ooze. Venous: Dark colored blood. Arterial: blood is bright red and appears in spurts with heartbeat |
| Visibility of Hemorrhage | Evident: On the surface and can be seen Concealed: In a body cavity and not seen |
| Actions by nurse in evident bleeding due to hemorrahge | Sterile gauze pressure on area, elevate site to heart level, place on shock position( flat on back , legs elevated at degree, knees kept straight.) Surgeon called asap to return pt to OR for ligation |
| Blood replacement in hemorrahge | Infusion of crystalloid and possibly blood products, loss over is considered for blood administration. |
| Latex allergies sometimes related to | Allergies to fruits |
| Quality and Safety Nursing Alert during first sing of nausea post op | lightest indication of nausea, the patient is turned completely to one side to promote mouth drainage and prevent aspiration of vomitus, which can cause pneumonia, asphyxiation, and death. |
| Risk factors for PONV | female gender, age less than 50 years, history of nausea or vomiting after previous anesthesia, and opioid administration |
| GI stimulant Metoclopramide | Acts by stimulating gastric emptying and increasing GI transit time. Administration recommended at the end of procedure. Available in oral, IM, and IV forms. |
| Phenothiazine antiemetic Prochlorperazine | Indicated for control of severe nausea and vomiting. Available in oral, SR, rectal, IM, and IV forms. |
| Phenothiazine antiemetic antimotion sickness Promethazine | Phenothiazine antiemetic antimotion sickness Promethazine |
| Antimotion sickness Dimenhydrinate | Antimotion sickness Dimenhydrinate |
| Antiemetic Hydroxyzine | Control of nausea and vomiting and as adjunct to analgesia preoperatively and postoperatively to allow decreased opioid dosage. Available in oral and IM forms. |
| Antiemetic antimotion sickness Scopolamine | Used to prevent and control of nausea and vomiting associated with motion sickness and recovery from surgery. Available in oral, transdermal SC, and IM forms. |
| Antiemetic Ondansetron | Prevention of postoperative nausea and vomiting. Available in oral, IM, and IV forms. With few side effects, frequently the drug of choice. |
| postoperative cognitive dysfunction (POCD) and postoperative delirium. | both conditions, patients exhibit signs of cognitive impairment; however, POCD is of sudden onset in the postsurgical period and is associated with the use of several anesthetic agents |
| Treating older adults in POCD | Hydration, orient to enviroment, reasses doses of sedatives, if hypoxia presentation may be related to blood loss, electrolyte imbalance, |
| Patients with obesity have unique postoperative risks including | increased risk of venous thromboembolism (VTE), deep vein thrombosis (DVT), and pulmonary embolus (PE). |
| Indicators of recovery from surgery from PACU include | stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline. |
| flash pulmonary edema | occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation; tachypnea; tachycardia; decreased pulse oximetry readings; frothy, pink sputum; and crackles on auscul |
| COLLABORATIVE PROBLEMS OR POTENTIAL COMPLICATIONS | Pulmonary infection/hypoxia •Venous thromboembolism (VTE) (e.g., deep vein thrombosis [DVT], pulmonary embolism [PE]) •Hematoma or hemorrhage •Infection •Wound dehiscence or evisceration |
| Planning and Goals post op | optimal respiratory function, relief of pain, optimal cardiovascular function, increased activity tolerance, unimpaired wound healing, maintenance of body temperature, and maintenance of nutritional balance |
| Subacute hypoxemia | constant low level of oxygen saturation when breathing appears normal |
| Episodic hypoxemia | develops suddenly, and the patient may be at risk for cerebral dysfunction, myocardial ischemia, and cardiac arrest. Risk for hypoxemia is increased in patients who have undergone major surgery |
| Coughing post op is contraindicated in patients | intracranial surgery (because of the risk for increasing intracranial pressure), as well as in patients who have undergone eye surgery (because of the risk for increasing intraocular pressure) or plastic surgery |
| In the postoperative setting | (IV) route is the first-line route of administration for analgesia delivery |
| The POSS | is a tool developed to identify advancing sedation before it is compounded by continued opioid administration and results in clinically significant respiratory depression or apnea. |
| Epidural analgesia | involves a continuous infusion of local anesthetics through a catheter and is the most widely used neuraxial technique for acute postoperative pain |
| involves a continuous infusion of local anesthetics through a catheter and is the most widely used neuraxial technique for acute postoperative pain | A local opioid or a combination anesthetic (opioid plus local anesthetic agent) |
| A local opioid or a combination anesthetic (opioid plus local anesthetic agent) | involves the administration of a local anesthetic by a catheter between the parietal and visceral pleura. It provides sensory anesthesia without affecting motor function to the intercostal muscles. allows effective cough |
| For pain that is difficult to control, a subcutaneous pain management system may be used | nylon catheter is inserted at the site of the affected area. The catheter is attached to a pump that delivers a continuous amount of local anesthetic |
| If the patient has an indwelling urinary catheter, | hourly outputs are monitored and should not be less than 0.5 mL/kg/h or 25 mL/h; oliguria is reported immediately |
| Risk factors for altered wound healing include | poor nutrition, smoking, diabetes, and poor hygiene |
| Factors Affecting Wound Healing | Age of pt ( less resilient). Bathing: use chlorhexidine gluconate shower. Hypovolemia: Poor perfusion and hypothermia reduce oxygen for healing |
| local factors that may affect wound healing | Edema, inadequate dressing, too small too tight, Nutritional deficits, foreign bodies drainage accumulation and oxygen deficit |
| Clean surgical catergorie | Nontraumatic, Uninfected site, No inflamatin, no break in aseptic technique, no entry into respiratory, alimentary, genitourinary or oropharyngeal tracts. |
| Clean contaminated | entry into respiratory, alimentary, genitourinary, alimentary, oropharyngeal, tracts without unusual contamination, appendectomy, minor break in aseptic technique, mechanical drainage |
| Contaminated | Open, newly experienced traumatic wounds, Gross spillage from gastro tract, major break in aseptic thecnique, entry into genitourinary, biliary when urine or bile is infected |
| Dirty | Traumatic wound with delayed repair, devitalized tissue, foreign bodies or fecal contimination, acute inflamation, purulent drainage during procedure |
| preoperative phase | period of time from when the decision for surgical intervention is made to when the patient is transferred to the operating room table |
| intraoperative phase | period of time that begins with transfer of the patient to the operating room area and continues until the patient is admitted to the postanesthesia care unit |
| postoperative phase: | period of time that begins with the admission of the patient to the postanesthesia care unit and ends after follow-up evaluation in the clinical setting or home |
| Emergent surgery—Patient requires immediate attention; disorder may be life-threatening | Without delay Severe bleeding Bladder or intestinal obstruction Fractured skull Gunshot or stab wounds Extensive burns |
| Urgent—Patient requires prompt attention Within 24–30 h | Closed fractures Infected wound exploration/irrigation |
| Required—Patient needs to have surgery | Plan within a few weeks or months Prostatic hyperplasia Thyroid disorders Cataracts |
| Elective—Patient should have surgery | Elective—Patient should have surgery |
| Optional—Decision rests with patient | Optional—Decision rests with patient |
| Informed consent | patient’s autonomous decision about whether to undergo a surgical procedure. |
| latex allergy can manifest | a rash, asthma, or anaphylactic shock. |
| The STOP-Bang | is one assessment that may be performed (Snoring, Tired, Observed, Pressure, BMI, Age, Neck, Gender) to assess for the presence of OSA |
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