MedSurge Unit 1

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cswett
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127607
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MedSurge Unit 1
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2012-01-16 23:05:46
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Adult Med Surge LeMone Adams 30
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Adult 1, Med Surge, LeMone Ch 4, Adams Ch 30
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  1. Surgery
    • invasive procedure to diagnosis or treatillness, injury, or deformity
    • 3 Phases or perioperative nursing:
    • Preoperative
    • Intraoperative
    • Postoperative
  2. Informed Consent
    Disclosure of risks associated with the intended procedure

    Nurse should be present and protect client understanding

    • 1. Need for procedure in relation to Dx
    • 2. Description & purpose of procedure
    • 3. Possible benefite and potential risks
    • 4. Likelihood of a successful outcome
    • 5.
  3. Classification of Surgery
    • Classified by purpose, risk, or urgency.
    • Purpose:
    • Diagnostic - determine or confirm Dx
    • Ablative - remove diseased tissure, organ, extremity
    • Constructive - build tissue/ organs that are absent
    • Reconstructive - rebuild damaged tissue/ organs
    • Palliative - Alleviate symptoms (not curative)
    • Transplant - replace organs/ tissue
    • Risk
    • Minor- minimal risk
    • Major- extensive surgery with greater risk
    • Urgency
    • Elective
    • Urgent -necessary within 1 to 2 days
    • Emergency - immediately
  4. Surgery Zones
    • Unrestricted zone Ex: Front desk* street clothes fine
    • Semi-restricted zone Ex. OR hallways and storage area
    • * scrubs, shoe covers, and caps
    • Restricted zone Ex: OR suite* sterile scrub attire/ stay 12” away from field
    • Rationale: INFECTION CONTROL
  5. Inpatient Surgery
    Outpatient Surgery
    • Inpatient Surgery
    • Pt. is admitted to the hospital.
    • Increased costs.
    • Risk of hospital acquired infection.

    • Outpatient surgery
    • Pt. is not admitted
    • Little time for teaching
    • Must have ride home
  6. Preoperative Nursing Responsibilites
    • 1. Assessment
    • Baseline
    • Surgical risk factors
    • 2. Client Education
    • Post-op exercises
    • Incentive spirometer
    • 3. Nursing care
    • Informed consent
    • Pre-op check list
  7. Ischemia
    restriction in blood supply
  8. morbidity
    risk of incidence of a disease
  9. Pre-Op Diagnostic Tests
    • CBC
    • Electrolytes (Na K, Cl, Co2, Glucose)
    • PT/PTT - prothombin time/ partial prothombin time
    • Urinalysis
    • CxR - Chest x-Ray
    • Type and Cross
    • EKG
    • Pulmonary Function
  10. PT
    INR
    PTT
    • PT - prothombin time (prothombin is produced in the liver)- how long the blood takes to clot after thromboplastin and calcium are added to decalcified plasma
    • - used to test effectiveness of coumarin (warfarin) type of anticoagulant drugs, determine cause of unexplained bleeding, or assess ability of liver to synthesize blood clotting proteins
    • - Normal Values - 10 - 13 seconds but can vary by specimin manufacturer

    • INR - International Normalized Ratio - how long the blood sample takes to clot when certain chemicals are added - represents ratio of PT to control
    • Normal Values 2.0 - 3.0
    • >5.0 = high risk of bleeding
    • <0.5 = high risk of clot

    • PTT - Partial Thromboplastin Time
    • screen for general plasma deficiencies -useful to dectect presence of many types of bleeding disorders caused by defective or deficient circulating factors
    • - used to monitor heparin therapy - heparin is a short-acting anticoagulant that circulated in the plasma and will increase PTT
    • Normal Value 22.1 - 34.1 Seconds
  11. Preoperative Nursing Assessment
    • Psychosocial Assessment
    • Explore concerns/fears
    • Past experience with surgery of both patient and family
    • Determine knowledge deficits related to diagnosis, surgery

    • Past medical history
    • Review of systems
    • Functional Health patterns
    • Family history
    • Medication use- all Rx and OTC and herbals
    • Medication allergies- in particular Latex allergy

    • Priority physical assessments
    • Cardiac status
    • Respiratory status
    • Musculoskeletal/skin status
    • Nutritional status
    • Endocrine Status

    • Risks:
    • Obesity – decreased healing, dehiscence
    • Pregnancy- limits anesthesia
    • Elderly-esp. is surgery > 2 hrs.
    • Poor nutrition- poor healing
    • Alcohol consumption- DT’s, poor nutrition
    • Tobacco- risk of pneumonia, respiratory

    • Information gathering
    • Forms- Informed consent- preop check list
    • Open ended communication- Requires therapeutic communication skills- Needs to be ongoing
  12. Univeral Protocol
    • 2004 – by JCAHO
    • verify the procedure
    • Physically mark and initial surgical site - must be marked by someone who is involved in and will be present at the surgery
    • Take a time out before starting any procedure - verify correct patient, site , positioning, and procedure
  13. Preoperative Nursing Dx
    • Fear/anxiety
    • Knowledge Deficit
    • Risk for injury
  14. Preoperative Nursing Interventions
    • Preoperative teaching ( Knowledge deficit)
    • What to expect
    • Teaching in post op procedures
    • * leg and deep breathing exercises
    • * moving patient
    • * coughing and splinting
    • * ROM exercises

    • Legal preparation
    • * Informed consent is the responsibility of the physician.
    • * Requires adequate disclosure, sufficient comprehension and voluntary consent.
    • * Nurse responsibility- obtain and witness signature if patient appears fully informed.When in doubt physician needs to reinstruct.
  15. Day of Surgery Nuring Interventions
    • Make sure all pre-procedures complete
    • Administer pre-op meds
    • * Usually a combination of narcotics,sedatives, and antiemetics.
    • * Patient is NOT to get up after these are given.
    • * Review and clarify any pre-op orders if necessary

    • Transfer to surgery suite
    • * Confirm ID of patient
    • * Verbally ask patient- name- physician name- Type of surgery and body part- Check ID bands and medical chart numbers
  16. Intraoperative Care
    The priority nursing diagnosis when in the operating theater is Risk for Injury.

    • The circulating nurse is:
    • * responsible for formulating the plan of care based on the client’s unique needs
    • * the advocate for the safety and well being of the client
    • * Responsible for all documentation of care in the operating theater.
    • -oversees prep of OR (equipment)
    • - assists with transferring and positioning of client
    • -ensures aseptic technique
    • -assists all other team members

    • Scrub Person:
    • -handles sutures, instruments, and other equipment immediately adjacent to the sterile field
    • -may be RN or ORT (OR tech)
  17. Surgical Team
    • Surgeon- physician perform the procedure - responsible for all medical actions and judgements
    • Surgical Assistants- physician, nurse, P.A.
    • Anesthesiologist or CRNA
    • Circulating nurse-highly trained RN
    • Scrub person or surgical tech.- nurse or OR tech.
  18. Fluoroscopy
    • real time continuous image of the internal structures of the patients
    • - scatter radiation present
  19. Intraoperative Care Complications/Nursing Diagnosis
    • Hypoventilation
    • -Ineffective breathing pattern
    • Oral trauma from intubation
    • -Impaired mucus membranes
    • Hypotension
    • -Decreased cardiac output
    • Cardiac arrhythmia
    • -Decreased cardiac output
    • Hyperthermia
    • -Ineffective thermoregulation
    • Malignant hypothermia
    • -Ineffective thermoregulation
    • Peripheral nerve damage
    • -Impaired mobility
    • -Pain
  20. dyspnea
    shortness of breath
  21. hypoxia
    lack of O2 to tissue - locally or systeically
  22. Iontophoresis
    delivery of charged molecules across intact skin using a small electric current - newer method of pain control
  23. Analgesia
    • absence of sensibility to pain.
    • the relief of pain without loss of consciousness.
  24. 3 Types of Anesthesia
    • General
    • Local or Regional
    • Conscious Sedation
  25. General Anesthesia Characteristics
    • Complete loss of sensation
    • Complete loss of consciousness
    • Complete loss of autonomic reflexes
    • Combination inhaled, IV and IM medications
  26. Local or Regional Anesthesia
    • Loss of sensation
    • No loss of consciousness
    • No loss of autonomic reflexes
    • “Caines” topically or injected
    • Anesthesia of choice if general is contraindicated.
  27. Conscious sedation
    • Depressed level of consciousness
    • Can maintain own airway and autonomic reflexes
    • Can follow commands
    • Use a combination of meds.- Hypnotics(Versed, Diprivan)
  28. Pre-anesthesia medications
    • Sedative/hypnotics- might give the night before to < anxiety. Anti-anxiety
    • Opioids & non-opioid analgesics
    • Anti-emetics - effective against nausea and vomiting
    • Anti-cholinergics - blocks acetylcholine - blocks actions of the PNS such as oral and respiratory secretions - used to decrease risk of aspiration
  29. Malignant Hyperthermia
    • Unexpected elevation in temp. after exposure to general anesthesia(inhalants & IV succinylcholine)
    • Thought to be an autosomal dominate disease
    • Can occur up to three days after surgery
    • Good family pt./history

    • S/S:-fever (105-111)
    • * Acidosis (resp. & met.)
    • Muscle rigidity
    • * Warm, mottled skin
    • Tachycardia
    • * Arrhythmia/CV collapse

    • Treatment
    • * Lower body temp. (hyperthermia blanket, coolfluids)
    • * Monitor urine output
    • * Monitor VS
    • * Treat arrhythmias
    • Tx:
    • Triggering agent D/C
    • O2 administered with non-rebreather mask
    • Dantrolene - muscle relaxant
    • Measures to decrease core body temp
    • Uninary catheter - monitor urinary output
    • blood gas and pH tested
    • Na HCO3 given if metabolic acidosis
  30. Post Anesthesia Care Unit (PACU)
    • Common post-op respiratory problems
    • Aspiration
    • * Risk for aspiration
    • Airway obstruction
    • * Ineffective airway clearance
    • Hypoxemia- pulse oximetry below 93%
    • * Impaired gas exchange
    • Hypoventilation
    • * Ineffective breathing pattern
  31. Atelectasis
    collapse of all or part of the lung
  32. Post Anesthesia Care Unit (PACU)
    Nursing respiratory assessment
    • Chest movement and symmetry
    • Accessory muscle use
    • Breath sounds
    • Vital signs
    • Pulse oximetry
  33. Post Anesthesia Care Unit (PACU)
    Implementations for respiratory nursing diagnosis:
    • (PACU)Implementations for respiratory nursing diagnosis:
    • Proper positions
    • Airway protection
    • Deep breathing techniques- “smell the flowers, blow out the candles”
  34. Post Anesthesia Care Unit (PACU)
    Common cardiovascular problems
    • Hypotension (Collaborative Problem)
    • Hypertension (Collaborative Problem)
    • Arrhythmias (Collaborative Problem)
  35. PACU - Nursing cardiovascular assessment
    • Frequent vital signs
    • Notify anesthesia provider of:
    • Systolic BP > 160 or < 90
    • Pulse > 120 or < 60
    • Narrowing pulse pressure
    • Progressive downward pattern on serial BP
    • Irregular rhythms
    • Significant change from preoperative baseline vitals
  36. PACU - Nursing cardiovascular Implementations
    • Hypotension-give O2 and anticipate a fluid bolus
    • Hypertension-correct source of sympathetic stimulation ( pain, distension,hypothermia)
    • Arrhythmias-correct the source
  37. Post-Op Monitoring
    • Adequate airway and respiration
    • Monitor VS frequently
    • Neurologic LOC
    • Hypo or Hyperthermia
    • Monitor Urine
    • Drains and Dressings
    • IV solutions
    • Pain
    • Nausea and vomiting
    • Head to toe assessment
  38. Post-Op Nursing Dx
    • Acute pain
    • Risk for Infection
    • Risk for Injury
    • Ineffective Breathing Patterns
    • Ineffective Airway Clearance
  39. Collaborative Problems
    conditions the nurse cannot manage independently

    The nurse’s role is to monitor for these conditions and collaborate with the appropriate health team member

    • Examples
    • Hemorrhage R/T ineffective vascular closure, alterations in coagulation.
    • Thrombophlebitis/embolism R/Tdehydration, immobility, vascular manipulation
    • Paralytic Ileus R/T bowel manipulation,immobility, medications
    • Urinary retention R/T positioning, pain,fear, medications.
  40. The Elderly and Surgery
    • Elderly patients have special surgical needs.
    • Respiratory System
    • *Diminished airway reflexes and cough

    • Cardiovascular System
    • * Myocardium Weakness

    • Hypothermia
    • * less subcutaneous tissue, muscle,slow metabolic rate
    • Pain
    • * more intense, confusion, impaired circulation and sensory
  41. Immediate Post-Op Care
    • On admission back to your unit
    • * Assess vital signs-highest priority
    • * Assess surgical site
    • * Assess lines and drains
    • * Review post-op orders

    • Immediately after major surgury assess
    • -q 15 mins for 1 hour
    • -q 30 mins for 2 hours
    • -q 60 mins for 4 hours
  42. Post Op Care
    • Ongoing care:
    • Pain management
    • Positioning
    • Splinting
    • Early ambulation
    • Monitor respiratory and cardiovascular status
    • Monitor collaborative problem
    • Monitor lines and drains
    • Plan for discharge
  43. Post Op Complications on the Unit
    • > Hemorrhage
    • > Urinary retention
    • > Arrhythmia
    • > Urinary tract infection
    • > Venous thrombosis
    • > Wound Complications
    • * infection
    • * dehiscence
    • * evisceration
    • > Pulmonary embolism
    • > Hiccoughs
    • > Paralytic ileus
    • > Immobility
  44. Diaphoresis
    excessive sweating
  45. Four Stages of Wound Healing
    • I. Surgery to day 2, inflammation, > WBC’s,epithelial cells, T 100 F.
    • 2. days 3-14, decrease WBC’s with collagen tissue and granulated tissue.
    • 3. 15-days 6 wks., collagen strengthens with raised pink scar tissue.
    • 4. Several months-one year, tissue constricts with smaller, flatter white scar tissue.
  46. Types of Wound Healing
    • Primary intention- well approximated
    • Secondary intention- gaping irregular, heals by granulation.
    • Tertiary intention- granulation healing and scarring
  47. Drainage/Exudates
    • Serous-clear, yellow plasma, thin
    • Sanguineous- serous and RBC’s, thicker
    • Purulent- WBC’s, bacteria, debris, odor- color and odor vary with organism
  48. Pain
    • -Described as an unpleasant sensory &emotional experience associated with actual or potential tissue damage.
    • -Affected by cultural influences and is what the patient says it is.
    • -Considered to be the 5th vital sign
  49. Pain Types
    Acute Pain < 6 mos. With tissue damage (sympathetic v. parasympathetic responses)

    Chronic Pain > 6 mos. With irritability, depression and insomnia.

    • Nociceptive Pain (normal process of stimuli)
    • *somatic pain (bones, joints, muscles, skin)
    • * visceral pain (organs)

    • Neuropathic (abnormal process)
    • * Central (phantom pain, reflex sympathetic)
    • * Peripheral (polyneuropathic, nerve root pain)

    Referred pain (felt at site different from injury)
  50. Discharge Plans
    • Discharge begins with admission
    • Patient/Family Education
    • Psychosocial Support
    • Return MD visit
    • Optimum respiratory/circulatory function, diet, meds (antibiotics, analgesics)
    • Adequate hydration and body temperature
    • Adequate renal function, safety in ADL

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