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81 Cards in this Set
- Front
- Back
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Herbal supplements that increase bleeding
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Feverfew
Garlic Ginger Ginko Biloba Ginseng Vitamin E |
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Herbal supplements that will prolong anesthesia
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St John's Wart
Valerian Kava |
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Risk for latex allergy
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Healthcare workers
avocado banana potatoes kiwi hay fever eczema asthma |
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High risk for atelectasis and hypoxemia
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COPD and asthma (may require preop inhaled beta agonist (albuterol)
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Smokers and quitting for surgery
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encouraged to quit 6 weeks before procedure--> decrease risk for complications
- greater years and number of packs = greater risk - similar to NPO requirements |
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Increased risk of pulmonary complications in patients with:
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- smokers
- COPD/asthma - Sleep apnea/snore - Obesity - Spinal, chest or airway deformities - Neuromuscular disease **May need pulmonary function tests and ABGs |
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Post operative (Emergence) delirium can occur with:
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dehydration
hypothermia adjunctive medications (antiemetics) and especially kids |
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Renal dysfunction contributes to:
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F/E imbalances
Increased Infection risk Impaired wound healing Altered response to meds and their elimination--adjust meds, especially insulin **Blood glucose will be more volatile because insulin comes from kidney |
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History of urinary retention may need
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pre-op catheter
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Mobility aids
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bring to surgery (can, walker, etc.)
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Report problems affecting neck and lumbar spine
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Anesthesia care provider because of spinal or epidural, may also affect positioning or if they have numbness normally and itsn't a result of surgery
-- can affect airway management and anesthesia delivery |
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Neuropathy surgery risks
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Gastroparesis (higher ileus risk, N/V)
Hypoglycemia unawareness (will pass out, etc.) Pressure ulcers Silent ischemia |
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Type 1 DM risk for ketosis
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q1h glucose monitoring, especially if on insulin pump
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DM patients
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need A1c before surgery
Serum glucose tests morning of surgery (baeline) Clarify with physician or ACP if usualy insulin dose is taken (especially if early case, like first thing in morning) |
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Immunocompromised patients
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Don't have normal infection signs (malaise and fatigue are important!)
delayed wound healing and risk for infection may need to taper meds |
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Obese patients
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- stresses cardiac and pulmonary systems
- increased risk for dehiscence and infection - slower recovery - slower wound healing -need extra padding to prevent ulcers and identify hapbits that may affect healing (ie caffeine) |
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Hepatic system problems in patients
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- increased time for anesthesia recovery and drug sensitivity
- Increased risk for clotting disorders (clotting factors made in liver) |
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Type and screen
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COULD need blood, find out Rh and type-- done on all OB and lots of surgeries
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Type and cross
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EXPECT to have blood administered, blood designated for pt (AAA, liver surgery, sometimes hysterectomies, joint, hip, anything really bloody)
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#1 PREOP TEACHING
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Consent form
* Nurse does not given informed conset, just witness it Dr needs to answer quations and it the pt competent to give consent? |
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Additional pre op teaching
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Coughing and deep breahting
Pain management What to expect Post surgical plan, some pts go to ICU and are even on ventilator *safety and movement, inform of tubes, monitoring devices or special equipment that will be used *provide written material |
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Informed Consent must include
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- adequate disclosure
- understanding and comprehension - voluntarily given consent *Surgeon is responsible for obtaining consent (nurse gets it and witnesses, verify pt has understanding) * Permission may be withdrawn at any time Medical emergency may override need for consent |
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Unrestricted areas
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- personnel in street clothes interact with those in scrubs
- Holding and information areas (preop)- family visiting can relieve anxiety |
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Semirestricted areas
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- peripheral support areas and corridors with only authorized people
- must wear surgical attire and cover all head and facial hair |
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Restricted areas
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- Operating rooms
- Scrub sink areas and clean core - surgical attire, head covers, and masks required |
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Don't forget to apply the:
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GROUND! to pt so pt doesn't get electricuted
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Barbituate IV induction agents
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Thiopental
Methohexital - rapid (<5min) |
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S/E of barbituate IV induction agents
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Decrease in BP
tachycardia respiratory depression (pt not intubated yet) - minimal repeated doses --> hangover |
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Non barbiturate hypnotics for IV induction
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Amidate
Propofol - good for hemodynamically unstable and for short, outpt procedures |
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S/E of non-barbiturate AMIDATE IV induction agents
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- myoclonia
- N/V - hiccups - adrenocortiaol inhibition |
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S/E of non-barbituate PROPOFOL for IV induction
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- bradycardia
- dysrhythmias - decrease in BP - apnea - phlebitis - N/V - hypertriglyceridemia (its milky fat) |
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Inhalation agents (halothane, enflurance, desflurane)
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- enter through alveoli
- rapid excretion by ventilation (POST OP BIG BREATHS!)--? pain will be apparent at this time, assess and treat for pain early! ** |
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Complications of inhalation agents
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Coughing
laryngospasm Bronchospasm Increased secretions (all above can lead to airway obstruction!) Respiratory depression (especially cause they are combined with narcotics) |
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Opiods adjunct to anesthesia
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Fentanyl (goes a long way, IV)
Sufentanil (cousin of fentanyl) Morphine--> hypotension (pooling) Hydromorphone (Dilauded) **give Narcan for respiratory depression--> but remember PAIN will come back immediately! |
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Bensodiazepine (Versed, Valium, Ativan) antagonist
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Romazicon
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Neuromuscular (paralytic) blocking agents
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Succinycholine (SUCCS)
Norcuron Pavulon Ardurant ***must sedate patient along with giving a paralytic!*** **Monitor airway/diaphragm closely becasue the reversal can wear of post op and they won't be bale to expand chest well (minimal chest excursion) - may last longer than procedure and reversal agents may not be affective in residual effects** These are sometimes given for laryngospasms with ventilator, intubation, etc. |
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How to reverse Neuromuscular blocking agents
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Anticholinesterase agents
** Neostigmine** |
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Monitoring if pt had neuromuscular blocking agents
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- observe for airway patency and adequacy of respiratory muscle movement
** Lack of movement or poor return of reflexes and strength may indicate need for ventilator - Apnea related to paralysis |
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Antiemetics
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prevent N/V associated with anesthesia
- Zofran - anapsine - scopalamine |
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Dissociative Anesthesia
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**Ketamine
- interupts associative brain pathways while blocking sensory pathways, pt appears catatonic - profound analgesia lasting into post-op *may cause agitation and hallucinations -used for quick anesthesi (like popping joint in place in ER) **book says provide a quiet, calm environment for recovering pt |
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Malignant hyperthermia
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- rigidity of muscles (early sign)
- creatinine released--> affects kidneys - hyperthermia - death **Dantrolene (Dantrium) is treatment- 36 vials available anywhere in OR or PACU** **Succinlycholine (Anectine) along with volatile may be trigger (Antothane) - glucose and insulin for hyperkalemia (muscle breakdown) - bicarb for metabolic acidosis - diuretic to maintain urinary output - warming dilunt will speed dissolving of Dantrolene |
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Tubes
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empty all tubes before leaving PACU
know EBL (estimated blood loss) |
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Important post anesthesia report
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- drains, EBL, about pt and surgery
- unexpected events during surgery - hypotension (can lead to renal failure) - baseline and most recent vitals and monitoring trends - results of intraoperative laboratory tests |
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Cardio response to inadequate O2
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HTn first then hypotension
tachy then brady Dysrhythmias (PVCs) decreased O2 sat- finger saturation may not be acurate because of cold |
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Integumentary system signs of inadequate O2
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-cyanosis
- delayed cap refill flushed and moist (diaphoretic) - nail neds? cold feet? pulse? |
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Respiratory system signs of inadequate O2
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- tachy to absent respirations
- accessory muscles - abnormal breath sounds (should be bilateral, shouldn't have a lot of wheezing, may have secretions so tell to take a deep breath--> may have to suction) - crackles, wheezes, grunts, "silent chest" - Abnormal ABG's |
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Renal system signs of inadequate O2
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low urine output (<0.5mL/kg/hr)
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#1 cause of airway obstruction
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tongue
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oral airway
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once have gag reflex can't use--- but can use nasal trumpet
* careful if had spinal or cervical, cant hyperextend --do jaw lift As long as pt has an airway then side lying is good |
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Hypoventilation tx
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Paralytic reversal agent
may need narcan May require intubation and ventilation |
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Post op hypertension
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- sympathetic nervous system stimulation
- pain - anxiety - bladder distention - respiratory compromise - hypothermia - preexisting HTN (may not have taken meds) - revascularization after vascular and cardiac surgery |
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Causes of Dysrhythmias post op
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Other than MI
- hypokalemia/hyper - hypoxemia - Hypercapnea - Alterations in acid-base - circulatory instability - preexisting heart disease * Hypothermia - pain - surgical stress ** Anesthetic agents |
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I Liter of water =
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1kg (2.2lb)
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Hypothermia
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core temp less than 95 degrees F (35 degrees C)
-elderly, debilitated, Intoxicated, long surgical procedure, prolonged anesthesia be aware if pt can't shiver (lou erics, spinal cord injury, etc) |
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Hypothermia increases risk for:
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- Compomised immune system (infection, pneumonia risk)
- Bleeding - Cardiac events - Impaired wound healing - Altered drug metabolism - Pain - Shivering (uses more O2!) |
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Treatment for post op shivers
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- oxygen
- Demoral (only time can use!!!) - shivering is a passive way to rewarm body Active rewarming is with blankets, etc. |
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Temperatures after surgery
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95 hypothermia up to 12 hrs
up to 100.4 is normal, above is possible infection in first 48h After first 48h, temp above 100 could be infection |
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Record temperatures q____ post op
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q4h for 48 hrs
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S/S of excess fluids
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full, bounding pulse, JVD, increased BP, cerebral edema, pulmonary congestion
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S/S of fluids deficits
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check specific gravity and I&O
- sympathetic nervous system and peripheral vasocontstriction--> - BP down, HR up - low cerebral perfusion - tachypnea - daily weights - look at turgor and mobility |
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Irrigate NGt with?
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Normal saline
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PACU discharge criteria
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PACU:
- pt awake (at baseline) - vital signs baseline or stable - No excess bleeding or drainage - No respiratory depression - O2 sat >90% - Report given From phase II/outpatient: - all PACU criteria met - no IV opioids for 30 min - minimal N/V - voided (if approprite) - able to ambulate (if appropriate) - responsible adult to accompany pt - written discharge |
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Normal NG/G tube drainage
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up to 1500 mL/day
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Normal T tube (bile) drainage
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500 mL/day
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Normal chest tube drainage
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notify physician if more than 100mL/hour
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AAA risk factors
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men
over age 65 smoking (any!) congenital (Marfans) Atherosclerosis HTN Diabetes Inflammatory aortitis Prior blunt trauma |
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Manifestations of upper aortic AAA
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- no symptoms
- dysphagia (esophageal pressure) - coronary ischemia - distended vena cava, edema of head and arms |
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Manifestations of middle/lower AAA (abdominal)
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- no symptoms
- abdominal or back pain - pulsing mass or bruit in abdomen - mottling of feet or ties (blue toe syndrome) |
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Complications of AAA
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exsanguination (rupture) -->
- hypovolemic shock (may lead to multiple organ dysfunction syndrome) - Renal failure - bowel ischemia - Lower extremity ischemia (may lead to gangrene, amputation) - pressure ulcers - MI |
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Emergent surgical mortality
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highes in women and older patients (32-94% for emergent)
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Indications of rupture of AAA
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- Diaphoresis
- Pallor - tachycardia - Hypotension - Abdominal, back (Grey Turners sign), groin pain - Change in LOC - Pulsating abdominal mass |
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Hypotension after AAA surgery
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may reduce graft patency (need enough BO for keep patent)
**Know MD's BP parameters! |
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High risk of what after AAA surgery?
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MI and dysrhythmias
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Hypertension after AAA
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Hypertension may cause leakage of blood around area- diuretics may be indicated for HTN
know dr parameters ** Prevent and early recognition of hypoxia! - effective pain control |
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Changes in peripheral pulses after AAA surgery
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notify provider! assess both sides
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Infection risk after AAA surgery
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**High risk for sepsis
-rare but possible - broad spectrum antibiotics - monitor body temp - monitor WBCs and differential - maintain nutrition - Attention to asepsis with wound care - Prevent infection at central cath sites - prevent cather related UTI |
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Gi risk after AAA surgery
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paralytic ileus (pooping puts pressure on grafts and if AAA ruptured then bowel may be narcotic)
- retroperitoneal bleeding - NG tube low intermitten suction** (irrigate prn per order with NS, I and O of tube) - early ambulation |
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bowel ischemia S/S
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- no bowel sounds
- fever - abdominal distention - diarrhea - bloody stools ***Immediate reoperation needed! |
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Most at risk for neurologic problems after AAA if:
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if AAA was ascending aorta or aortic arch involved
- control BP - maintain oxygenation - report alterations from baseline immediately |
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Peripheral circulation monitoring after AAA surgery
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- depends on location
- hourly peripheral pulse monitoring --may need doppler, mark pulse sites NOTIFY SURGEON IF: -cool, pale or mottled extremity - decreased or absent pulse |
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Decreased renal perfusion may occur with:
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- embolization of thrombus plaque
- hypotension - dehydration - prolonged aortic clamp time - excessive blood loss |
