52B Exam III- C/R/S (Perioperative)

it can be good, in normal amounts, by kicking in the sympathetic nervous system.

• General
• the unknown
• loss of control
• loss of love from significant other
• Spacific
• malignancy of tumor
• anesthesia
• dying
• pain
• disfigurement
• permanent limitations

• 1. Diagnostic: finds origin/cause of disorder (exploaratory laparotomy)
• 2. Curative: resolves a health problem (mastectomy)
• 3. Restorative: improve functional ability (knee replacement)
• 4. Palliative: relieve symptoms (tumor debulking)
• 5. Cosmetic: enhance physical appearance (facelife)

• Elective
• Urgent
• Emergent

• simple-removal of tissue only
• radical-removal of tendons and muscle too (radical mastectomy)

• difficult postop care
• anger
• depression
• confusion

• seperation anxiety (keep parents around as much as possible)
• unfermilliar surroundings (take pt to rooms before operation, use "play activities")

preop teaching to answer questions and decrease anxiety

• alpha - vasoconstriction
• beta₁ - + Inotropic effects (increase force of heart contractions), and + Chronotropic effects (increase in heart rate)
• beta₂ - vasodilation and increased renin release from kidneys

alpha and beta receptor cites are stimulated (sympathetic ns activated) causing vasocnstriction (helps maintain BP), and + Inotropic/Chronotropic effects on heart (maintains BP and helps perfuse vital organs)

decreased activity - can lead to constipation, gas pain, and anorexia

• glucocorticoid secretion for the adrenal cortex is increased. this increases the breakdown of protein, CHO, and fats for healing and energy.
• this can cause weight loss or high blood glucose (so watch in diabetics)

• increased ADH secretion can cause increased fluid volume/fluid overload
• Na retention by kidneys (renin-angiotension system activation) can cause increased fluid volume and K loss (bad for muscle/heart function)

• decrease in blood volume (ex: from surgery) causes kidneys to release renin
• renin stimulates angiotensin production, constrict blood vessels, and increases adosterone secretion from the adrenal cortex
• aldosterone causes Na resorption in tubules of the kidney which holds on to water and increases blood volume

• age- altered physiological respense, presence of chronic disease
• duration of surgey
• smoking
• nutrition- malnutrition (decrease resources for healing), obesity (heavy chest = resp issues, wound seperation increase, DVT form decreased movement)

• Chronic pulmonary disease - (COPD) don't respond well to anesthesia, prone to infection (pneumonia), C02 retention
• Cardiovascular - meds must be adgustes, atherosclerosis inhibits blood vessel constriction
• Renal - electrolyte imbalances, decreased kidney function (means they can't excrete anesthesia so doses must be lowered)
• Diabetes - decreased wound healing

• irritates bronchus
• increases secretions
• decreased ventilation/ability to remove secretions

• informaed consent
• teaching (routines, where they will be, equipment, treatments-dressing change, pain managment, TCDB, how to pillow splint, IS, hob up 30-45 degrees)
• NPO 6-8 hr before
• bowel prep
• preop meds
• checking labs/tests (CBC, UA, ECG, X-ray, coag)
• skin prep

• cramping
• dehydration
• electrolyte imbalance
• fatigue
• vasovagal response (decrease blood to brain can cause pt to pass out)
• irritation

• reduce anxiety (valium)
• promote relaxation
• reduce pharyngeal/gastic secretions (atropine-also inhibits GI motility)
• prevents laryngospasms
• decreases amount of anesthesia needed

• pt must be...
• -mentally and physically competent (no opiats onboard)
• -a legal adult
• must be voluntary
• pt must understand procedure, risks, benifits, and alternatives
• pt must have had all their questions answered satisfactorily
• interpreter must be used if necessary

to witness signature (can reinforce teaching)

• charges of assault and battery or negligence
• exceptions:
• -emergency
• -waived right
• -physician invokes therapeutic privilege
• -obvious risk
• -risk couldn't be predicted

betadine or chlorhexidine body scrub/wipes 1-2 days before OR

bracing incision/abdomen by holding a pillow

• thoracic/upper abdominal surgery (pt won't want to deep breathe due to pain)
• smoking
• chronic lung disease
• tight abdominal binders/body casts
• obesity (don't breathe deeply)
• elderly

• ankle pumping and gluteal squeezes
• they promote venous return (venous stasis can cause DVT formation whcih can lead to pulmonary emboli)

• prevents decubitus ulcers
• increases peristalsis
• decreases pain
• reduces risk of DVT

• (see preop checklist)
• check ID band
• NOP
• empty bladder (if not cathed)
• check allergies
• advanced directives (DNR status)
• give "en rout to OR" preop meds
• RN to sign off
• to OR by guerney

reduction of LOC with IV drugs

• to dull/decrease intensity or awareness of pain
• reduce LOC while keeping defensive reflexes (gag reflex=no need to intubate)

the MD

• endoscopies
• cardiac caths
• closed fracture reduction
• PTCA (percutaneous transluminal coronary angiogram-like a cardiac cath)
• cardioversion
• electric convulsant therapy
• other special but short procedures

• NOP for several hours
• informed consent signed
• baseline VS
• special procedure room/PAC Unit (post anesthesia care unit)

direct IV push

• Opioids - demerol, morphine, fentanyl
• Sedatives/hypnotics (benzodiazapines) - valium, versed, ketamine

• the MD supervises and the RN must...
• have advanced training in IV med administration
• manage airway and ACLS (advanced cardiac life support)
• monitor airway, LOC, ECG, 02sat, VS q 15min (until fully awake and responsive)

• Narcan for Opioids
• Romazicon for benzodiazepines (both have "Zs" in them)

• circulating nurse
• scrub nurse/surgical tech
• specialty nurse
• surgeon and surgical assistant
• anesthesiologist or CRNA (certified RN anesthesiologist)

when the entire team stops to varify that it is the correct patient, procedure, and site

• burning from improper grounding during electrocautery (electric cauterization)
• pressure ulcer formation
• obstruction of circulation/respiration/nerve conduction

surgery using toold inserted through small incisions instead of one large one.

C02 is used to inflate the abdomen and, if it isn't all removed before incisions are sutured, when the pt sits up it can travel up to the shoulders and cause pain. have pt lay down until C02 can be absorbed by the body

• steril - free from living microorganisms
• clean - free from dirt
• contaminated - the introduction of dirt of microorganisms onto something formerly clean or steril

12 inches

• the waist to the shoulders
• and
• the sleeves to 2 inches above the elbows

reversable loss of conciousness by inhibiting CNS

temporary disruption to spacific are of sensation (epidural, spinal, nerve block)

directly applies anesthesic agent (topical)

an inherited disease where pt experiences a drastic rise in temperature when given anesthesia

• malignant hyperthermia
• overdose of anesthesia (pt won't wake up)
• unrecognised hypoventilation (lungs don't fully fill when ventilated)
• complications with spacific anesthesia agents (can cause kidney, heart, GI paralysis)
• intubation complications

• inhalation: intake and excretion of anesthesia by lungs via a mask
• IV injection: barbiturates, katamine, and propofol through the blood

• hypnotics
• opioid analgesics
• neuromuscular blocking agents

• moving pt from table to bed
• jarring guerney during transport
• reactions to drugs/anesthesia
• loss of blood/body fluids (check EBL)
• cardia arrhythmias/heart failure
• inadequate ventilation
• pain
• decreased sympathetic response

provide ongoing evaluation and stabalization of patients to anticipate, prevent, and treat complications after surgery

to prevent tongue from closing off their airway

>100ml/hr

pain can be either the diagnosis or etiologic factor)

children, because it produces toxic metabolites

• increased satisfaction with pain control so pt uses less
• decreased pulmonary complications
• earlier ambulation
• shorter hospital stay

the patient! no PCA by proxy

• consistantly use a pain/sedation rating scale
• follow standard policy for monitoring over-sedation and adverse reactions
• assess sedation using minimal spoken and tactile stimulation

• N/V
• decreased or absent paristalsis (due to anesthesia time, bowel handling, and opioid use), can last up to 24 hours

• Phase I - (1 to 3 days) inflammatory response, blood flow reestablished
• Phase II - (3 to 14 days) collagen fills in (epithielization)
• Phase III - (2-6 weeks) more collagen and compression of blood flow
• Phase IV - (several months) shrinking and contraction of scar

between the 5th and 10th days after surgery

partial or complete seperation of the outer wound layers (splitting open)

total seperation of all wound layers and protrusion of internal organs

on admission to the PACU and hourly thereafter

they provide an exit for air, blood, and bile to prevent deel infections and abscess formation during healing

antibiotics and irrigations