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111 Cards in this Set
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Anesthesia
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the absence of normal sensation
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Analgesia
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pain relief without producing anesthesia
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Anesthesiologist
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a licensed physician educated and skilled in the delivery of anesthesia who also adds to the knowledge of anesthesia through research or other scholarly pursuits
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Anesthetist
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a qualified RN, dentist, or physician who administers aneshtetics
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Surgery
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tx of injury, dz, or deformity through invasive operative methods: minor (presenting little risk to life) or major (possibly involving risk to life)
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NPO
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nothing by mouth for at least 8 hrs, past midnight, recently 2 hrs without clear liquids
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Preoperative meds
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most scheduled meds are continued until the time of surgery w just enough water to swallow
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exceptions: insulin, oral antihyperglycemics, NSAIDS, anticoagulants
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NPO - infants and small children
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4 hours or less
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sedation
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reduction of stress, excitement, or irritability and involves some degree of CNS depression
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sedatives are administered based on:
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physical condition, weight, mental state, and the procedure being performed
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JC standards for monitoring of sedated clients
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BP measured at frequent and regular intervals and the HR and O2 be continually monitored by pulse oximetry, continual monitor of respiration rate and pulmonary ventilation Cardiac rhythm for clients with significant cvd or predisposition to dysrhythmias is monitored with EKG
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capnography
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measures a client's CO2 concentration - displayed as a waveform
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length of time to recover from sedation depends on:
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health of the client, properties of the drugs used, other drugs the client may be taking, amount of sedative drugs administered
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amnesia
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inability to remember things
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regional anesthesia
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region of the body is temporarily rendered insensible to pain by injection of local anesthetic
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preop phase
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begins with client's decision to have surgery
ends with txfr of client to operating table fear of unknown is the most prevalent fear prior to surgery nurse can most easily allay fear through client education, preoperative teaching |
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Diagnostic surgery
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removing tissue for dx
ex: biopsy for cancers |
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Curative
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removal of dz gallbladder, CABG, appendectomy
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Restorative
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herniorrhaphy, knee replacement
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palliative
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pt has mets to colon from liver CA - fix bowel obstruction for comfort of the patient
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cosmetic
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nose, lips, breast implants
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emergency
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gun shot wound
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urgent
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GI bleed
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required
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fractures
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elective
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gastric bypass
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preop physiologic assessment
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cognitive first
physical exam review of the client's labs and dx studies type and amount of screening depend on the age and condition of client, nature of surgery, and surgeon's preference |
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variables affecting surgical status
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age
nutritional status fluid and electrolyte status respiratory status cardiovascular status renal and hepatic status neurological, musculoskeletal status integumentary status endocrine and immuniological status medications |
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assess surgical pt list
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name
age DOB IV - where? rate? Surg site - dx cap refill surg date, time voiding? cath? Last bm? dressing? neuro checks 2-4hours |
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antibiotic
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within 30 minutes of cut time - sent with pt for on-call to OR
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psychosocial health assessment
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nurse elicits client's perceptions of surgery and expected outcomes
client's coping mechanisms, knowledge level, and ability to understand provide clients opportunity to express their spiritual values and beliefs |
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surgical consent
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informed consent - signed by client and witnessed by another person granting permission to clien't physician to perform procedure described by physician.
Dr's responsibility nurses obtain and witness client's sig, ensure client signs voluntarily and is alert |
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Preop teaching
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answer questions and concerns about surgery
ascertain client's knowledge of intended surgery ascertain need fo additional information provide information in a manner most conducive to learning |
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physical preparation
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Identify client.
Identify op site prepare the skin check vitals dress client appropriately allergies verify NPO remove dentures and bridgework empty bladder identify sensory deficits give preoperative meds as ordered instruct family and significant others where to wait |
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intraoperative phase
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time during the surgical experience that begins when the client is transferred to operating room table and ends when client is admitted to the PACU
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Surgical Team
Sterile |
Surgeon
First assistant scrub nurse sterile field |
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surgical team
nonsterile |
anesthesia provider
circulating nurse |
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asepsis
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the absence of pathogenic microorganisms
aseptic technique is a collection of principles used to control and/or prevent the transfer of pathogenic microorganisms from sources within and outside the client |
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surgical hand scrub
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removes soil and transient microorganisms from hands and forearms
watches, rings, and bracelets removed fingernails must be short, clean, healthy hands and forearms should be free of breaks in skin integrity |
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surgical skin prep
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goal of skin prep at client's incision site is to lower the number of microorganisms on and near incision site
check allergies - iodine cleanse in circular motion (clean to dirty) |
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introperative nursing care
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client is to be free from infection and injury related to positioning, foreign objects, or chemical, physical, and electrical hazards
skin integrity and fluid and electrolyte balance are to be maintained |
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postoperative phase
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the time during the surgical experience that begins with the end of the surgical procedure and lasts until client is discharged from medical care
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Postop Nursing Care
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recovery from anesthesia and effects of surgery- can recognize and treat anesthetic, surgical complications quickly
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Post op VS
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every 15 min for 1 hr
every 1/2 hr for 2 hrs every hr for 4 hrs |
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ambulatory surgery
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surgical care performed under general, regional, or local anesthesia involving less than 24 hrs hospitalization
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sedation used to:
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decrease awareness of events, relieve anxiety, control physiologic changes often accompanying anxiety, ease the induction of anesthesia
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During sedation, client must remain _____ and in _____ of his own airway and breathing
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conscious, control
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conscious sedation
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minimally depressed LOC during which the pt retains his ability to maintain a continuously patent airway and respond appropriately to physical stimulation or verbal commands produced by the administration IV sedative, hypnotic, and opioid drugs
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conscious sedation objectives
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mood alteration
maintenance of consciousness and cooperation elevation of pain threshold partial amnesia prompt safe return to adls maintains own airway and protective reflexes |
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procedures utilizing conscious sedation
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I&D
wound dressing changes suturing of lacerations fracture reduction bronschoscopy gastroscopy colonoscopy ballon angioplasty |
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LOS - Light
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intact protective reflexes, normal respiratory and eye movement
lethargic amnesia may or may not be present |
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LOS - Deep
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weak or absent protective reflexes
responds to painful stimuli difficult to arouse |
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General anesthesia
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unresponsive to stimuli
unconscious absent protective reflexes |
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conscious sedation
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protective reflexes intact
able to maintain airway permits appropriate response by client to verbal command or physical stimulation |
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conscious sedation meds
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valium versed ativan MS demerol
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equipment needed for conscious sedation
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oxygen
crash cart - reveral meds nearby romazicon narcan pulse ox telemetry bp monitor |
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Malignant Hyperthermia
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hypermetabolic crisis caused by excessive Ca+ released by muscles
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MH S/S
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increased ETCO2 (end tidal CO2), tachycardia, hypercapnia, muscle rigidity, EKG changes late, rhabdomyosis, dark urine
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TX for MH
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DANTROLENE 36 vials
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Naloxone - Narcan
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narcotic antagonist
0.1 - 0.2 mg IV titrated at 2-3 min |
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Flumazenil - Romazicon
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benzodiazepine antatgonist
0.2 mg over 30 sec within 1-2 min after med injected may be repeated at 1 minute intervals |
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airway obstruction or respiratory depression
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position head appropriately, suction or insert airway, stimulate and have deep breathe, administer supplemental o2, manually ventilate with ambu bag, if vomiting pt on side on modified trendelenburg position
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Oversedation
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maintain ABCs
use reversal agents monitor respiration |
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cardiac arrhythmias
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brady secondary to hypoxemia, vagal stimulation
tachy second ary to pain, anxiety, hypoxemia, hypovolemia PVCs ST hypoxemia, hypovolemia EKG immediately |
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Spinal Cord - meninges - Dural Mater
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dense fibrous connective tissue - outermost and toughest layer
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Arachnoid mater
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thin membrane, separated by subdural space
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Pia mater
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delicate connective tissue, clings tightly to spinal cord and brain
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subarachnoid space
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between pia mater and arachnoid mater - contains cerebrospinal fluid (about 150 mL)
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spinal cord terminates at:
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L1-L2
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Site for intrathecal (spinal)
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L3-L4 or L4-L5
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Epidural
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medications diffuse across dura and subarachnoid space and bind to mu receptors located in the substantia gelantinosa within the spinal cord
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epidural for analgesia
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provides selective analgesia - reversible blockade of spinal cord opioid receptors that alter pain transmission to brain while leaving sensation, motor and sympathetic function essentially unchanged
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epidural catheter - how long
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48- 72 hrs
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Epidural contraindications
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infection at proposed puncture site
generalized systemic infection coagulopathy/anticoagulant therapy increased intracranial pressure allergic reaction to narcotics prior laminectomy pts with high INR, PT, PTT or bleeding pathologies |
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nursing care for epidural
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routine post-op vs then q4h
extremity movement q 4h dressing q4h HOB elevated 30 degrees at all times read infusion pump q 1h x 24h then q 4h sedation and pain level assessments sensory/neurological assessments epidural site presence of complications I&O cath for 48 - 72 h removed only by anesthesia preservative free meds and sterile NS only pulse ox continues and 4 h after d/c no iv/im/po narcs/seds except as ordered by anesthesiologist |
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epidural complications
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dural puncture
pruritus urinary retention n/v |
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spinal
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procedures below diaphragm:
total joint replacement prostatectomy knee arthroscopy beneficial for clients with cardiac or respiratory dz clients with hx of airway problems r/t intubation or reactive airway dz |
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spinal contraindications
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risk of developing hematomas that could compress nerve roots or spinal cord resulting in neuro deficit or permanent paralysis
uncorrected hypovolemia - severe hypotension systemic or localized infection allergy increased intracranial pressure acute neurologic dz scoliosis neurologic abnormality |
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spinal assessment
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continuous monitoring HR, rhythm, Sa02, VS q5-15 until stable,
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t4
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nipple line
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t6
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xiphoid process
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t10
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umbilicus
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L1
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hip
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L2,3
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thigh
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L4,5
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calf
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S1
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toes
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assess return of motor function
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morot function conducted by large nerve fibers returns before other functions
as sensory functions return, detect light touch and pressure before temp pain (alcohol pad) returns from hip to feet - higher dermatomes recovering 1st may return to one side before the other - assess bilaterally |
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complications of spinal - hypotension
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venous pooling
iv fluids elevate legs assess VS frequently vasopressors duration 1 hour after IV admin Neo-Synephrine constricts peripheral veins and arteries increases systemic vascular resistance 15-20 min after admin |
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spinal - bradycardia
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high spinal block
adm atropine glycoprrolate |
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spinal - urine retention
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persistent sensory or autonomic blockade of bladder
insert urinary catheter |
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spinal - postdural puncture headache
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leak of spinal fluid irritating dura mater
position dependent - keep head flat increase IV and PO fluids S/S frontal/occipital HA tinnitus, diplopia, n/v, photophobia analgesics autologous blood patch (20 mL of pt's blood into Epidural space to serve as hemostatic plug closing the dural tear and prevent csf leakage |
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spinal - back pain
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need placement
local tissue irritation reflex muscle spasm patient positioning positioning during surg teach may last 10-14 days rx with analgesics |
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Spinal analgesia
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commonly used to control postoperative pain from major surgeries
morphine or fent with spinal anesthetic opioid hastens onset of analgesic and prolongs analgesic effects comes into direct contact w spinal cord effective at fraction of dose you'd give via epidural route |
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spinal analgesia opioid selection
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type of procedure
expected length of time needed for pain control drug's characteristics |
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monitor spinal recovery
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respiratory depression: resp < 8 seconds - peak time for occurrence is 8-10 hours
urinary retention - assess I&O palpate bladder, insert cath prn pruritus - treat w lotion, cool cloth, benadryl or nubain N/V - administer antiemetics as ordered |
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benefits of spinal analgesia
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decrease incidence of MI in OR
superior post-op pain relief improved lower extremity blood flow decreased intraoperative blood loss decreased postop ileus decreased number hospital days decreased incidence of dvt improved pulmonary toilet earlier ambulation possible |
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general anesthesia
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involves unconsciousness, complete insensibility to pain, amnesia, motionlessness, and muscle relaxation
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four stages of general anesthesia
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induction - going to sleep, includes inserting oral airway
maintenance - anesthesia maintained with combination of IV and inhaled drugs emergence -drugs allowed to wear off recovery - may take days or weeks |
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PQRSTU
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provokes/palliative
quality region/radiation timing how is your pain affecting you? |
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postop complications - immediate
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hemorrhage
hypovolemic shock hypoxia/hyercapnia vomiting (aspiration) hiccoughs anxiety/fear hypothermia/hyperthermia unstable blood pressure airway problems emergence delirium electrolyte disturbances n/v pneumothorax MI increased pain |
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Atelectasis
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collapse of alveoli
causes: histamine rxn, mechanical vent **onset - first 48 hours** S/S - temp 102, tachy, resltess, tachypnea (24-30), diminished/absent breath sounds, dullness to percussion, crackles, decreased PaO2, cyanosis, pleural pain |
prevention - turn q 30 min - 1 hr
deep breathe and cough q 1 hr ambulate soon and often medicate to reduce pain splinting force fluids TX - incentive spirometry sup O2 Elevate HOB TCDB q 1-2 h force fluids monitor response to tx, monitor for onset of pneumonia |
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gastric distention
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accumulation of swallowed air and gastric juices in presence of ileus r/t decreased peristalsis and intestinal manipulation - all surgical clients at risk
**onset 24-36 hours S/S - increased circumference of abdomen, c/o fullness/gas pains, tympanic abd on percussion |
Prevention - avoid air swallowing
position changes q 2h ambulate early and often warm fluids to stimulate (check bs) TX - frequent turning to move air up in chair ambulate nasogastic tube to low suction assess abd circumf assess bs, passage of flatus rectal tube |
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N/V
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risk - general ansthesia, narcotic analgesics, presence of airways, presence of NG tube
S/S - c/o N/V |
prevention - avoid stimulating gag reflex, avoid rapid movements, remove airways as soon as possible
TX - NPO, side lying position or turn head to side, change positions slowly, oral care, antiemetics, cool cloth to throat, head, narc r/t duramorph regional anesthesia |
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Ileus
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failure of peristalsis
onset 24-36 hr TX - monitor for return of bs, offer only sips of water until return of bs, monitor for distension, monitor for passage of flatus |
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intestinal obstruction
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onset 3rd - 5th day
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paralytic ileus
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S/S no bowel sounds, abdominal distension, no passage of flatus, ng drainage green to yellow 1-2 L/24 h, hiccoughs, tympany
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TX - monitor for return of bs, offer only sips of water until return of bs, monitor for distension, monitor for passage flatus
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pneumonia
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onset 36-48
prevention - provide regorous tx of atelectasis, prevent aspriation, early ambulation, tcdb, no smoking TX - tcdb q 1h, sputum C&S, frequent mouth care, administer o2, increase fluids, administer antipyretic as ordered, elevate HOB, incentive spirometry |
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pulmonary embolism
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onset - 7th to 10th day
S/S sharp stabbing chest pain, effected by respirations, may be localized RLL, |
prevention - ROM, ambulation, prevent DVT/thrombophlebitis, do not massage legs, adequate hydration, tcdb, avoid valsalva, TED hose
TX - administer O2, reduce anxiety, left side, head down, IV fluids, analgesics, prepare for fibrinolysis/anticoagulation |
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thrombophlebitis
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7th -14th day
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UTI
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3rd - 5th day
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wound infection
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5th - 7th day
if strep 24-48 hrs |
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dehiscence/evisceration
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7th-14th day
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