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Sx Classifications: Seriousness
Sx Classifications: Urgency
Sx Classifications: Purpose
- Procurement of Organs
- Bleeding disorders
- Diabetes mellitus
- Heart disease
- Liver disease
- Heavy smoker
- Chronic respiratory disease
- Immunological conditions
- Abuse of street drugs
- Chronic pain
Symptoms of Shock
- Low BP
- Rapid HR
- Moist skin (cold and pale)
Types of shock
Types of anesthesia
- Regional (spinal, epidural, peripheral block)
- Conscious sedation
- Flat or to side (unless contraindicated)
- Administer antiemetic w/ persistent N/V
- Keep pt. warm
- Maintain airway. (SPIRO-CARE HOURLY )
Possible Post-op Nursing Diagnosis
- Alteration in comfort
- Impaired skin integrity
- Risk of ineffective airway clearance
- Risk for volume deficit
- SCD: bathing and groomin
What is early ambulation helpful for?
- abd. distention
- generalized muscle weakness
Some early post-op complications
- Abd. distention
- Hyperstatic pneumonia
- Urinary retention
- Wound hemorrhage
Some later post-op complications
- Wound infection
- Wound dehiscence
- Wound evisceration
- Pulmonary embolus
- Malignant hyperthermia
Overall possible Surg pt. Nursing diagnosis
- Airway clearance, ineffective
- Breathing patterns, ineffective
- Constipation, risk for
- Coping, family, ineffective
- Fear or Anxiety
- Fluid volume deficit or excess, risk for
- Infection, risk for
- Mobility impaired, risk for
- Skin integrity impaired
- Knowledge deficit
- Planning starts early-starts at admission
- Plan on continuity of care
- Discharge instruction sheet
- Document how pt. went home
- Follow up
Causes of abdominal distention?
Surgical manipulation of bowel, swallowed air
Symptom of atelectasis?
Symptoms of hypostatic pneumonia?
Shallow resp. and fluid accumulation
Reasons for hypoxia?
- respiratory depressants
- poor positioning
Reasons for nausea?
- eating or drinking before peristalsis returns
Reasons for shock?
- loss of fluids and electrolytes
- VS instability
Reasons for urinary retention?
- local edema
Reasons for wound hemorrhage?
- slipping of suture
- dislodged clot
- wound evisceration
Reasons for thrombophlebitis?
- venous stasis
- irritation from IV needles
- blood clot
Causes of wound infection?
- poor technique
- "dirty" wound
- decreased immune system
Causes of wound dehiscence?
- (seperation of wound edges)
- old age
- unusual strain
What is wound evisceration?
protrusion of abd. viscera through incision
Symptoms of pulmonary embolus?
- pleuetic pain
- Improve recognition and response to changes in pt's condition
- Hold a "Time out" before any procedure in the hospital
- A pre-op verification checklist is requires
What is a core measure?
- A specific item that can easily be measured in many hospitals.
- JCAHO uses this method in order to make valid comparisons between hospitals.
- Uses standardized sets of valid, reliable, evidence-based "core" measures that can be used to track progress in making hospitals safer for everyone.
What is SCIP?
- Surgical Care Improvement Project
- This project is a national quality partnership of organizations focused on improving surgical care.
- AKA- Propofol
- General anesthesia
- Given pre-op to decrease oral/respiratory secretions
- Might increase HR
- antianxiety agent
- pre-op sedation, conscious-sedation, post-op amnesia
- AKA- diazepam
- relief of anxiety
- skeletal muscle relaxation
- decreased seizure activity
What do antiemetics generally do?
to manage nausea and vomiting
What do opiod analgesics generally do?
Management of moderate to severe pain
What do non-opiod analgesics generally do?
Used to control mild to moderate pain and/or fever
General use of anti-infectives?
treatment and prophylaxis of various bacterial infections
What are cephalosporins?
- chemical modifications of the penicillin stucture.
1st generation cephalosporin?
1st gen - used for skin/soft tissue infections. primarily active against gram-positive bacteria.
2nd generation cephalosporin?
2nd gen - have increased activity against gram-negative micro-organisms and few cover anaerobes
3rd generation cephalosporin?
More active against gram-negative bacteria. However, the 3rd gen is less effective against gram-positive cocci.
4th generation cephalosporin?
Has antimicrobial effects comparable to the 3rd gen. It has the advantage of coverage against many Pseudomonas species and activity against gram-positive pathogens.
- Are synthetic, broad-spectrum agents with bactericidal activity.
- The antimicrobial spectrum for fluoroquinolones includes gram-negative and positive aerobes.
What do opioid antagonists do?
They bind to opiod receptors and competively displace the opiod analgesics from their receptor sites.
- AKA - dolasetron
- AKA - prochlorperazine
- AKA - metoclopramide
- AKA - hydroxyzine
- AKA - trimethobenzamide
- AKA - ondansetrom
- AKA - naloxone
- Opioid antagonist
Tylenol & codeine (#3 & #4)
- AKA - Meperidine
- AKA - hydromorphone
- AKA - hydrocodone and acetaminophen
- AKA - oxycodone and aspirin
- AKA - Oxycodone and acetaminophen
- AKA - promethazine
- AKA - nalbuphine
- AKA - cefazolin
- 1st generation cephlosporins - antibiotic
- AKA - cephalexin
- 1st generation cephlosporins - antibiotic
- AKA - ceftriaxone
- 3rd generation cephlosporins - antibiotic
- AKA - levofloxacin
- AKA - ciprofloxacin
- 0-18 months
- Gender is assigned, genitals sensitive
- males may have erections
- females vaginal lubrication
- 1-5 years
- Identifies gender
- labels body parts correctly
- parent of opposite sex is focus of love
- 6-12 years
- Becomes curious about sex roles and reproduction
- friends are usually same sex
- 12-18 years
- sex characteristics develop
- friendships may include the opposite sex
- may engage in masturbation and sexual activity
- 18-65 years
- Establishes family to include sexual activity, values and family roles
- Between 40-65 hormone production decreased leading to climacteric in both sexes
- frequency of sexual activity decreases
- men and women experience altered sexual functioning
Sexuality key concepts
- acceptance of one's body image
- sexual identity
WHO definition: Sexual Health
- "a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity"
- sexual intercourse
- refers to the physical part of a relationship, genital sexual activity
- gender/all developmental stages in life
FSH and LH stimulate the testes to release the male sex hormone, testosterone.
FSH and LH result in the production and release of mature egg cell and in the production of female sex hormones, estrogen and progesterone.
Factors affecting sexual behavior
the problem has existed most of the individuals adult life
- sexual problem is recent in origin
- Painful intercourse due to vaginal lubrication
Manifestations of altered sexuality
- sexual abuse
- inhibited sexual drive
- ejaculatory dysfunction
- orgasmic dysfunction
How does sexual dysfunction impact activities of daily living?
- Decrease in self esteem and in self confidence
- interpersonal relationships may be affected
- less emotional energy to concentrate on important aspects of daily living
What is asepsis?
The absence of germs or microorganisms
What is medical asepsis?
- Those actions designed to reduce the number of pathogens in an area and decrease the likelihood of their transfer.
- Use of technique of clean to dirty (hand washing, changing pt's bed, cleaning thermometer, ect)
What is surgical asepsis?
- Actions to make or keep an object or person free of all microorganisms.
- Sterilization destroys all microorganisms and their spores.
What are nosocomial infections?
- Hospital acquired
- Higher in critical care areas (sicker pts and more invasive procedures)
Some normal self-care prevention of biological hazards.
- Storage and handling of food
- Hand washing
- individual tooth brush, ect.
- covering cough or sneeze
- Precautions regarding sexuality
- keeping newborns out of crowds
- cleaning, dishwasher, laundry
- liquid soap, paper cups in bath room
- keeping contagious disesae people at home
The normal defense mechanisms against infection
- respiratory tract
- urinary tract gastrointestinal tract
What are the steps to the infection chain?
- Infectious agent
- Portal of exit
- Means of transmission
- Portal of entry
- susceptible host
Breaking the chain: Use of infectious agents
Breaking the chain: Reservoir
- Good dressing techniques
- non contaminated water pitchers
Breaking the chain: Means of transmission
- good hand washing
- good asepsis with dressings
- isolation techniques
- proper disposal of urine
Breaking the chain: Portal of entry
- good care of skin and mucous membranes
- no contaminated food or food serving utensils
Breaking the chain: Susceptible host
- identification of high risk pts
- assessment and maintenance of nutrition and fluid balance
- promoting therapeutic health habits
- admin meds and assessment of effects of medicaiton on pt's defense mechanisms
- supporting body's defenses
The course of infection by stage
- Incubation - entering to 1st symptoms
- Prodromal - nonspecific to more specific
- Illness - specific to type of infection
- Convalescence - acute symptoms to good health
- vancomycin resistant enterococcus
- enterococcus bacterium that is resistant to the antibiotic vancomycin
- infected pts show clinical s/s
- colonized pts do not show s/s
- category - contact (and mask for respiratory tract symptoms
- causes pseudomembronous colitis
- may be due to antibiotic use
- primary symptom - diarrhea (stool sent to lab)
Why can antibiotic use lead to c.diff?
Antibiotics diminish normal colon flora and may result in overgrowth and release of toxins which injure mucosa
Treatment of c.diff?
- Contact precautions
- May treat with oral flagyl or vancomycin
- Must wash hands with soap and water
What is MRSA?
- Methicillin Resistant Staphylococcus Aureus
- Staph bacteria have become resistant to various antibiotics including penicillin-related antibiotics
What precautions are to be taken with MRSA?
Precautions may be droplet, contact. ect. depending on where infection is
- indicates presence of bacteria but absence of signs and symptoms of infection
- once initial infection for MRSA and VRE is treated, patient can remain colonized for indefinite period of time
What to do with airborne precautions?
- The door must be closed at all times
- N95 particulate respirator mask (orange duckbill) MUST BE WORN BY ALL WHO ENTER
What to do with droplet precautions?
mask must be worn when working within 3 feet of the patient
What to do with contact precautions?
- gloves upon entry to the room
- gown when you will be working directly with the patient
3 things to breaking cycle of infection
Definition of medical asepsis?
procedures used to reduce the number of microorganisms and prevent their spread
Definition of surgical asepsis?
procedures used to eliminate all microorganisms including pathogens and spores
Definition of disinfection?
elimination of pathogenic organisms, with the exception of spores, on inanimate objects.
Definition of sterilization?
process of destroying all microorganisms, including spores
The 7 principles of surgical asepsis?
- 1. sterile object to sterile object
- 2. sterile object on sterile field
- 3. sterile object or field out of range of vision or an object held below person's waist is considered contaminated4. contamination by prolonged exposure
- 5. wet = contaminated6. fluid flows in the direction of gravity
- 7. edges of sterile field or container = contaminated
- autoclave (moist heat under pressure)
- used for surgical instruments
used in sterilizing drugs, plastics and food
- requires object to be in boiling water for at least 15 minutes
- bacterial spores and some viruses resist
Ethylene Oxide gas
used to sterilize rubber, paper, plastic items
used for instruments and equipment
Which procedures at bedside require sterile aseptic technique?
- sterile dressing changes
- urinary catheter insertions
- preparing and administering injectable medications
Describe an acute wound?
- orderly and timely reparative process
- sustained restoration of anatomical and functional integrity
- caused by trauma from sharp object
- wound edges clean and intact
Describe a chronic wound?
- not orderly and timely reparative process
- unsustained restoration of anatomical and functional integrity
- caused by friction, secretions, pressures
- wound edges may be necrotic, drainage maybe present
- skin edges approximated
- little loss of tissue
- low risk of infection
- healing is rapid and primarily by collagen synthesis
- Wound edges not approximated
- large and irregular
- involves loss of tissue
- takes longer to heal and has greater risk of infection
- (burns, pressure ulcers, severe lacerations)
Wound is initially left open and later closed
When does does hemorrhage occur?
usually occurs within 24 to 48 hours
When does does infection occur?
commonly occurs on 4th or 5th day with post-operative wound
When do you get a culture and sensitvity specimen of a wound?
before starting antibiotics
When does does dehiscence occur?
commonly 3 to 11 days
When does does evisceration occur?
- medical emergency
- IMMEDIATE ACTION
What are the complications of a fistula?
- increases risk of infection
- fluid/electrolyte imbalance
Definition of inflammation?
protective response of body tissues to irritation or injury
Definition of infection?
infectious agent is living and growing in the tissues and overcomes the body's normal defenses
S&S of an infection?
- elevated WBC
- purulent and odorous drainage
Factors influencing healing
- general health
- oxygen availability
- wound stress
When assessing the appearance of a wound what 7 things should you note?
- 1. size
- 2. appearance of tissue
- 3. edges appoximated
- 4.signs of inflammation or infection
- 5. amount of discharge with color and odor
- 6. discomfort
- 7. drains (hemovac, jackson-Pratt (JP), penrose)
What are the 5 purposes of wound dressing?
- to protect wound from microorganism contamination
- promote healing
- support or splint the wound site
- promote thermal insulation of the wound surface
- provide maintenance of high humidity between wound and dressing
What are the main surgical dressing layers?
- Contact or primary layer
- Absorbent layer
- Outer protective layer
Types of dressings?
- Woven guaze sponges
- non-woven sponges
- non-adherent guaze
Goals for wound treatment
- keep the ulcer bed continuously moist
- type, size and depth of wound
- controlling exudate
- caregiver time
- area where wound is located
- hospital protocol
What is important to teach with meds going home
- Take meds exactly as prescribed
- evenly spaced intervals of dosing
- take medication for the full length of time prescribed or until all the drug is gone
- infection may return if the full course of therapy is not completed
- any leftover medication should be appropriately discarded
- provide list of adverse reactions, drug & food interactions