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343 Cards in this Set
- Front
- Back
What is the pre-operative phase?
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the time the decision is made to have surgery until the pt is transported into the operating room.
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Wht is minimal invasive surgery?
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aka bloodless surgery
-done through fiberoptics,recovery time less |
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What type of surgery involves little risk to life?
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minor surgery
|
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What type of surgery may involve risk to life and where is it usually performed?
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major surgery.
-usually done in hospital |
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What are 6 general types of surgery?
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-diagnostic
-curative -restorative -palliative -cosmetic -ablative |
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What is a diagnostic surgery for?
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to determine the cz of the symptoms
|
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What is a curative surgery for?
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to remove a diseased part
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What is a restorative surgery for?
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strengthens a weakened part
ex: total knee replacement |
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What is a palliative surgery for?
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relieves the symptoms w/o curing the dz.
ex: colostomy to remove bowel obstruction when have cancer |
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What is a ablative surgery for?
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excises tissue that may contribute to or worsen the pt's existing med. cond.
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How does the sympathetic nervous system respond to surgery?
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there is an incr amt of norepinephrine secreted that results in peripheral vasoconstriction.
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What does peripheral vasoconstriction help maintain during surgery?
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helps maintain BP during surgery by maintaining fluid vol w/ bld loss in surgery.
-may decr urinary output for about 24 hrs. |
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Surgery may also cz an increase in aldosterone secretion which results in what?
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decreased GI activity and sodium retention.
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What is the hormonal response to surgery and what does it result in?
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an incr in the secretion of glucocorticoid secretion. Results in a mobilization of stored fats & amino acids for energy.
-this is for healing. May see incr bld sugar first 24 hrs. |
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What hormone has incr secretion during surgery that helps to maintain bld volume?
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anti-diuretic hormone.
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What is the metabolic response to surgery?
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an incr in carbohydrate metabolism,fat metabolism, & protein metabolism.
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6 factors that affect pt's response to surgery?
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-age
-meds -medical history -prior surgical experience -health/family history -type of surgery planned |
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How can age affect a pt's response to surgery?
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-very old & very young likely to have more complications
-cardiovascular changes w/ aging -respiratory changes w/ aging |
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How can meds affect a pt's response to surgery?
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-tobacco use: incr incidence of pulmonary complications
-Rx drugs -illegal drugs:react to anesthesia diff. -OTC drugs |
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How do bronchodilators work?
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work by stimulating the beta2-adrenergic receptors allowing the smooth muscles of the bronchi to relax.
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What do beta2-adrenergic receptors do?
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cz vessels to relax.
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Do bronchodilators have any effect on the inflammatory process?
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No.
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3 examples of bronchodilators?
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-beta2 agonists
-cholinergic antagonists -methylxanthines |
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What do beta2 agonists bind to?
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bind to the beta2 adrenergic receptors.
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When beta2 agonists bind to the beta2 adrenergic receptors it czs an incr in?
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czs an incr in the intracellular level of cAMP resulting in relaxation of the smooth muscle.
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What does cAMP stand for?
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cyclic adenosine monophosphate
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Are beta2 agonists short or long acting?
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can be short OR long acting
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What type of relief do short acting beta2 agonists provide?
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provide rapid but short term relief.
-Medication is delivered directly to the prob w/ minimal side effects |
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When are short acting beta2 agonists most effective?
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most effective if used at the beginning of an attack or if an attack is anticipated.
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Most commonly used short acting beta2 agonist?
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Albuterol
|
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How can short acting beta2 agonists be administered?
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either as a metered dose inhaler(MDI) or as a dry powder inhaler(DPI)
|
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Side effects of short acting beta2 agonists?
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-may cz tachycardia w/ too much use
-may cz dry mouth & throat -must use inhaler correctly to receive the correct amt of med -using a bronchodilator first may make other inhaled meds more effective |
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Where do long acting beta2 agonists deliver the med to?
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directly to the bronchioles.
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Long acting beta2 agonists are best used for?
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better used for prevention of attack
|
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2 examples of long acting beta2 agonists?
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-salmeterol(Serevent)
-formoterol fumarate(Foradil Aerolizer) |
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What are cholinergic antagonists aka?
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anticholinergic agents
-dry things up(especially czs dryness in mouth) |
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How do cholinergic antagonists work?
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work by blocking the parasympathetic nervous system so that sympathetic nervous system takes over czing bronchodilation & decr pulmonary secretions.
|
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How long acting are cholinergic antagonists?
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usually short acting
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How often must cholinergic antagonists be used?
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must be used several times a day.
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Example of a cholinergic antagonists?
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ipratropiun(Atrovent)
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When are methylxanthines used?
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used when the other drugs don't work
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How are methylxanthines administered?
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administered systemically, have side effects & narrow therapeutic ranges.
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2 examples of methylxanthines?
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theophylline(Theo-Dur) & aminophylline(Truphylline )qZ
|
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How are aminophylline drips given?
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have to be given by infusion pump.
-also has more side effect |
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Why do you need to monitor pts blood level when administering methylxanthines?
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bc they have a narrow therapeutic range which may be very close to what is needed to cz bronchodilation.
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What should theophyllin level be when pt taking methylxanthines?
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theophylline level should be 10-20
|
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What are the signs of methylxanthine toxicity?
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N/V/D:especially nausea,early sign of toxicity
-tachycardia -dysrhythmias -restlessness |
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What potentiates side effects of methylxanthine?
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Caffeine
|
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How are antiinflammatory agents given?
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systemically or by inhalation
|
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5 examples of anti-inflammatory agents?
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-corticosteroids
-inhaled anti-inflammatory agents -mast cell stabilizers -monoclonal antibodies -leukotriene antagonists |
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What do corticosteroids do?
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decrease inflammation by preventing the synthesis of mediators
|
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How can corticosteroids be given?
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as an inhaler or systemically
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Inhaled corticosteroids may help to?
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may help to prevent symptoms
|
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2 examples of corticosteroids?
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fluticasone(Flovent) & budesonide(Pulmicort)
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Side effect of corticosteroids?
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make the pt susceptible to oral infections
|
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Why are systemic corticosteroids only used for severe problems?
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bc they have serious side effects
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What do inhaled nonsteroid anti-inflammatory agents do?
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inhibit the release of inflammatory mediators 4m respiratory cells & WBCs
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Do inhaled nonsteroid anti-inflammatory agents reverse attacks?
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No. prevents attacks more than reverses them.
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How often must inhaled nonsteroid anti-inflammatory agents be used?
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must be used on a regular basis even if there are no symptoms.
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Example of inhaled nonsteroid anti-inflammatory agent?
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nedocromil(Tilade)
|
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What do mast cell stabilizers prevent?
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prevents the mast cell membranes from opening when an allergen binds to IgE.
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Do mast cell stabilizers reverse attacks?
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No. Helpful in the prevention of attacks more than reversing an attack.
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Example of a mast cell stabilizer?
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(Intal)
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How do monoclonal antibodies work?
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work by binding with IgE receptors sites on mast cells & basophils preventing allergens 4m releasing mediators 4m the mast cells & basophils.
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What is a monoclonal antibody helpful for conc. asthma attacks?
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more helpful in the prevention of attacks then during the attack
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Example of a monoclonal antibody?
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omolizumab(Xolair)
|
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How do Leukotriene antagonists work?
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work by either preventing leukotriene synthesis or blocking the leukotriene receptors
|
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How are leukotriene antagonists given?
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orally
|
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2 examples of leukotriene antagonists?
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-zafirlukast(Accolate)
-montelukast(Singulair) |
|
What should be monitored if a pt is on Singulair?
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liver function tests
|
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What type of meds are used for pneumonia?
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anti-infectives are used for all types of pneumonia unless czed by a virus
|
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5 common anti-infectives used for pneumonia?
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-Azithromycin
-Levofloxacin -Ticarcillin -Vancomycin -Ciprofloxacin |
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How can your medical/cardiac history affect the pt's response to surgery?
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-may need med clearance lots of times
-many times pulmonary,cardio,renal, & endocrine systems must be evaluated |
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How can previous surgery/anesthesia affect the pt's response to surgery?
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may have had a good or bad outcome that affects their feelings towards surgery
-also will let you know feelings towards anesthesia, allergies, etc. |
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How can family history affect a pt's response to surgery?
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may have a family hx of malignant hyperthermia
|
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Why is a pre-operative assessment done?
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to establish a baseline
|
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General things that will be assessed in a Pre-operative assessment?
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-vital signs
-allergies -cardiovascular system -respiratory system -renal/urinary system -neurological system -musculoskeletal system -nutritional status |
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What type of cardiovascular assessment will be done pre-operatively?
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-check for hypertension
-assess heart rate,rhythm,sounds -look for edema -assess the peripheral vascular system |
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What type of respiratory assessment is done pre-operatively?
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-assess breath sounds
-look for lung expansion -evaluate overall respiratory effort -look for clubbing of fingers |
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What type of renal/urinary assessment is done pre-operatively?
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-look at BUN & creatinine
-monitor F & E status -I & O |
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What type of neurologic assessment is done pre-operatively?
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-overall mental status
-assess for falls risk |
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What type of musculoskeletal assessment is done pre-operatively?
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-Will mobility be an issue?
|
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What type of nutritional assessment will be done pre-operatively?
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-malnutrition
-obesity |
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What type of lab data will be done pre-operatively?
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-blood tests(CBC:hemoglobin,hematocrit,WBC,RBC)
-urinalysis -x-rays:some hosp require CXR,EKG if pt over a certain age -other |
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What does a signed consent imply?
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implies that the client has the knowledge to understand the nature of the surgical procedure as well as the possible consequences.
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What is the order in which consent is obtained if an adult is unable to do so?
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-spouse
-adult child -parent -sibling |
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How can consent be given in an emergency?
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can be given over the phone(have 2 ppl listen)
-or faxed |
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What questions might you ask to assess a pt's psychological readiness for surgery?
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-Does the pt understand the proposed surgery?
-What previous experiences has the pt had with surgery? -Does the pt have any specific concerns? -What support systems does the pt have available to him? |
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What objective data can you look for r/t preparedness for surgery?
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-speech patterns:repetition of themes,change of topics,avoidance of topics
-degree of interaction of others -physical assessment:incr HR & RR,incr hand mvmt,incr perspiration,incr voiding |
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What type of medical interventions may be carried out prior to surgery?
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-diet: will want to know when last ate or drank
-bowel cleansing:for bowel surgery -skin prep:shaves uncommon. will clip sometimes |
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What is the goal of pre-op teaching?
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to decrease anxiety
|
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What should pre-op teaching include?
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what to expect during the surgical experience
|
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What does the amt of info in the pre-op teaching depend on?
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patients:
-background -interest -stress level -age |
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What should be taught concerning pre-operative tests?
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reason for and an explanation of
|
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What should be taught conc. pre-op routines?
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about NPO,prep,enema,etc.
|
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What information should be given to the family pre-operatively?
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-where they should wait
-where the surgeon will talk to them -how long it will be |
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What type of final assessment will be done on the day of surgery?
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-vs
-ID band -Bld band -labs/tests -nail polish off -gown on -bladder emptied |
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Some reasons for pre-op meds to be given on the day of surgery?
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may be given prior to surgery to decr anxiety,provide sedation,induce amnesia,decr saliva
|
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Why may narcotics be given pre-operatively?
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to reduce anxiety and promote relaxation but may depress resp, circulation,& GI motility
|
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2 examples of narcotics that may be given pre-operatively?
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-demerol
-morphine |
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Why may barbiturates be given pre-operatively?
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to reduce anxiety,promote relaxation & sleep but cz excitement or confusion in elderly.
|
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2 examples of barbiturates that may be given pre-operatively?
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-Nembutal
-Seconal |
|
Why may benzodiazepines be given pre-operatively?
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to reduce anxiety & promote relaxation but cz dizziness & headache.
|
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2 examples of benzodiazepines that may be given pre-operatively?
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-Valium
-Librium |
|
Why may neuroleptanalgesics be given pre-operatively?
|
promotes a state of indifference,decr motor activity,analgesia,antiemetic but also czs resp depression & hypotension
|
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Example of a neuroleptanalgesic that may be given pre-operatively?
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Fentanyl
|
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When should pt be ID'ed before sugery?
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pt should be ID'ed prior to going to OR & then upon arrival in OR. If having orthopedic surgery must be sure that the correct part is noted.
|
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When does the Intra-operative phase begin and end?
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begins when the pt is transferred to the operating table and ends w/ the transfer to the recovery room.
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What is the holding area?
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-may be used as an area where the pt waits for the OR to be ready
-nurse double checks the chart -procedures are done -visit by the anesthesiologist |
|
Common surgical team members?
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-scrub nurse/tech
-circulating nurse -anesthesiologist or CRNA -surgeon -second surgeon -others:student nurse,orthopedic rep,etc. |
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What are common duties of the circulating nurse in the surgical team?
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-oversees the entire operating room
-creates & maintains a safe environment -makes sure sterile technique is followed -accounts for equipment(instruments,sponges,etc.) -assists other team members as necessary -maintains communication |
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Responsibilities of scrub nurse/tech?
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-prepares sterile supplies & equipment
-assists the surgeon -accounts for equip. |
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Upon arrival of pt in the OR the circulating nurse should?
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-ask the pt to state his name
-check the pts name & # w/ his ID band -check the consent -rvw the chart -check for jewelry,glasses,dentures,etc. |
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Responsibilities of Anesthetist/CRNA?
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administration of the anesthetic agents
|
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Effects of anesthesia?
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-amnesia
-analgesia -hypnosis -relaxation |
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4 types of anesthesia?
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-general
-regional -local -conscious |
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What is general anesthesia?
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may be given IV or by inhalation. Blocks the awareness centers in the brain producing unconsciousness,body relaxation,& loss of sensation.
|
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What is regional anesthesia?
|
analgesia that occurs over a specific body area. May be given via spinal,Bier block,epidural. Pt is conscious.
|
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What is local anesthesia?
|
analgesia given over a limited tissue area. Pt is conscious.
|
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Important considerations for spinal anesthesia?
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-a type of regional anesthesia
-usually done on the lower ext. -pt remains awake during the procedure -Headache is a common post anesthesia prob |
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What should be done if pt has a headache post anesthesia?
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-keep the pt supine
-force fluids if allowed |
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What is conscious sedation?
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-the IV delivery of sedative,hypnotic,& opoid drugs to reduce the LOC but maintain a patent airway & to respond to verbal commands
-very short acting -nurse must monitor airway,O2 sats,EKG, & VS |
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What is malignant hyperthermia?
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-a life threatening complicaton triggered by the anesthetic agent. Only occurs in pts w/ an inherited defect in the membrane of the skeletal muscle.
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What levels rise in pts body during malignant hyperthermia?
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the pt's calcium level rises & metabolic rate incr dramatically.
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What may happen to pt if calcium level & metabolic rate is allowed to incr during malignant hyperthermia?
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pt may develop renal failure,DIC(clotting prob),neurological damage, & heart failure.
|
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Clinical manifestations of malignant hyperthermia?
|
-tachycardia(occurs first)
-unstable BP:usually goes up -tachypnea -muscle rigidity -skin mottling -rapidly rising body temp. |
|
Tx of malignant hyperthermia?
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-stop the admin of causative agent(1st step)
-ice -chilled IV fluids -diuretics -steroids -dantrium(med helps stabilize Ca & decr BMR) |
|
At the termination of surgery?
|
-dressings applied
-documentation done -moved 4m OR to PACU w/ circulating nurse & anesthesiologist |
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Upon arrival in PACU?
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-circulating nurse will give report to PACU nurse
-PACU nurse will do quick assessment |
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What will the quick assessment that the PACU nurse does contain?
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-assessment of airway
-vital signs -LOC -EKG |
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A more detailed report from the circulating nurse to the PACU nurse should include?
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-diagnosis
-surgical procedure -type of anesthetic agent used -any meds administered -any probs/complications -amt of fluid lost/given(EBL) -drains/lines/tubes -surgical site -dressing -rvw of medical orders |
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What is the goal of maintaining a patent airway?
|
goal is to prevent hypoxemia & hypercapnia:most common cz of this is airway obstruction & hypoventilation
-pt will have pulse oximeter on |
|
What are the causes of airway obstruction?
|
-relaxation of the tongue as a result of the anesthesia
-secretions *All noisy breathing is a sign of airway obstruction but don't have to have the noise to have an obstruction |
|
What is a pharyngeal airway?
|
-most common
-keeps airway open & the tongue forward until gag reflex returns -removed when pt awake & has gag & swallowing reflex back |
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Why is a pharyngeal airway not tolerated in a conscious pt?
|
bc it may stimulate vomiting or a laryngospasm
|
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What is an endotracheal airway?
|
-keeps the airway open by insertion of a tube into the pt's trachea
-may or may not be removed prior to leaving the OR -pts may complain of a sore throat -may be left in post-operatively in ICU |
|
What does the position to promote ventilation depend on?
|
-depends on the type of surgery,the pts size,the type of anesthesia used
|
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Position to promote ventilation?
|
initially pts are usually supine w/ the head hyperextended & with suction equipment ready
-recovery position: side lying when stable |
|
Why is oxygen almost always given to post op pts?
|
due to decr pulmonary expansion & areas of atelectasis.
|
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When should oxygen be given until post op?
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until pt is conscious,can take deep breaths on their own or as determined by bld gases or O2 sats(keep bw 92-98%)
|
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Circulatory complications occur post op due to?
|
hypotension & cardiac dysrhythmias:reason why VS are assessed so frequently in the PACU.
|
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What may hypotension post-operatively be caused by?
|
-moving the pt 4m the OR table to the stretcher
-the drugs or anesthesia given -loss of bld & fluids -dysrhythmias -pain |
|
What are the clinical manifestations of shock?
|
-weak,rapid,thready pulse
-skin cool & clammy -restless |
|
Interventions for hypotension?
|
-need to notify the doc
-elevate the legs but keep pt flat. Don't lower head. -give fluids(standing orders) -check for bleeding |
|
What may dysrhythmias post-operatively be czed by?
|
-decreased oxygen
-pain -hypovolemia *tx depending on the cz -new onset may be of concern |
|
Other interventions for the PACU?
|
-administer IV fluids
-monitor for F & E imbalances -maintain a safe environment -provide comfort |
|
What do most hospitals use to see if pt is ready for discharge from PACU?
|
-easily aroused
-stable VS -complications under control -return of sensation(regional anesthesia) |
|
Pain control post-op?
|
-remember assessment of pain is 5th vital sign
-maybe a combo of meds & other therapies -admin opioids/analgesics w/ caution so as not to mask another prob -may have a PCA pump -assess RR/pain complaints -assess elderly pts carefully |
|
What is the most common post op complication?
|
Pulmonary. prevent by coughing,deep breathing,sighing, & suctioning.
|
|
Why does atelectasis occur?
|
due to alveoli collapsing either due to a a mucus plug or a decr in surfactant.
|
|
What can be first sign of atelectasis?
|
unexplained rise in temp especially in the immediate post-op phase. Usually occurs in 24-36 hrs after surgery.
|
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Why does pneumonia occur?
|
occurs when secretions pool in the lower airway as a result of shallow breathing & immobility & then a pulmonary inf. occurs. Usually occurs 3 days after surgery.
|
|
Risk factors for pulmonary probs?
|
-inhaled anesthesia
-high abdominal or thoracic surgery -age -presence of COPD -smoking -resp depressant meds -pain:must be controlled for pt to breathe deeply -decr mobility -dehydration |
|
Deep Breathing exercises
|
-sit in semi fowlers or high fowlers postion
-hold hand lightly on abdomen -breathe in thru the nose slowly -hold breath for 3 secs -exhale thru pursed lips -repeat |
|
coughing exercises?
|
-do deep breathing exercise
-count to 3 -cough deeply 3 times *medicate pt first if if helps them to cough |
|
When is coughing contraindicated?
|
in brain surgery,spinal surgery, or eye surgery.
|
|
Incentive Spirometer(Triflow)?
|
-mechanical device that promotes sustained maximal inspiration
-pt takes a deep breath while trying to hold up a ball |
|
Yawn maneuver or sighing exercises?
|
-taking a deeper breath than normal
-usually take about 6 sighs/hr -allows the alveoli to be completely opened & therefore increasing the prod of surfactant |
|
Formation of ___ can occur postoperatively which can be a potentially life threatening complication of surgery.
|
formation of Clots.
|
|
What should be assessed r/t maintaining circulation on the nursing unit?
|
-check for pos. Homan's sign
-check for redness -incr circumference fo calf -complaints of numbness,tingling feeling |
|
Prevention of clot formation?
|
-TED hose
-SCD -don't allow pts to cross their legs/ankles -no pressure on popliteal area -no massage of the lower ext -leg exercises while in bed -early ambulation -meds:heparin,lovenox.aspirin |
|
Interventions for suspected DVT?
|
-notify doc
-put on bedrest(do first) & elevate the legs until able to contact the doc -anticipate anticoagulant therapy |
|
4 general things to watch for post-operatively?
|
-circulatory overload
-ileus -urinary retention/decr urine output -pain |
|
How can circulatory overload occur post-op?
|
due to incr IV fluids. Watch for congested breath sounds,weight gain,dyspnea,change in LOC.
|
|
How can an ileus occur post-operatively?
|
due to decr peristalsis. Watch for bowel sounds,nausea
|
|
How can urinary retention/decr urine output?
|
due to loss of bladder tone & body fluid during surgery. Watch for decr u.o., distended bladder.
|
|
If excessive fluid is allowed to accumulate post-operatively, what would occur?
|
-would interfere w/ O2 delivery
-alter the cell wall permeability -disrupt lymp flow & create dead space. |
|
What are tubes used for post-operatively?
|
tubes are used to prevent blockage or to add suction in order to help the tissue layers stay together.
|
|
Tubes...
|
tubes that have suction must have the suction maintained.
-documentation should include what is draining out & how much. |
|
Examples of tubes?
|
JP,hemovac
|
|
Things that affect wound healing?
|
-weight(obese)
-diabetes -PVD -steroids |
|
What does primary intent wound healing mean?
|
-way that most wounds heal
-incision is clean,straight,all layers of the wound are well approximated by suturing -heal w/ a minimum scarring |
|
What is secondary intent wound healing?
|
-used when the edges cannot be approximated
-fill in by granulation over a large area -more scarring |
|
What is tertiary intent wound healing?
|
delay bw injury & suturing
|
|
What is dehiscence?
|
-partial or total separation of wound edges
-czed by inf,poor wound healing,abdominal distention |
|
S/S of dehiscence?
|
-low grade fever lasting 3-4 days
-prolonged,increasing pain -serous fluid on dressing -c/o feeling like something gave way or pulling at the suture line. |
|
Interventions for dehiscence?
|
-notify the MD
-apply binder for support -remain calm,discourage coughing,moving until re-ordered by the doc -prepare for surgery |
|
What is evisceration?
|
-sudden,dramatic,bursting of suture line w/ abdominal contents protruding out
-czed by:inf,poor wound healing, abd distention |
|
S/S of evisceration?
|
c/o something popping,abdominal contents are outside the ab cavity
|
|
Interventions for evisceration?
|
-notify the MD stat,stay w/the pt
-cover the abdominal contents w/ moist gauze pads or sterile towels -keep the pt supine -remain calm -explain to the pt what happened -prepare for surgery |
|
What should be assessed for a smoking history assessment for pt w/ a respiratory disorder?
|
-pack years: how many packs smoked/day X # of yrs been smoking
-exposure to second hand smoke |
|
What should be assessed for a med history for pt w/ a respiratory disorder?
|
-RXed
-illegal |
|
Questions that should be asked during an assessment of pt w/ respiratory disorder?
|
-What is current prob & how is it manifesting itself?
-How long have you had? -Does it interfere w/ ADL's? -cough w/ or w/o sputum prod? -dyspnea? -chest pain? |
|
Diagnostic tests commonly done in pts w/ respiratory disorders?
|
-bld tests:CBC,ABGs
-sputum cultures:to see what's in lungs -CXR -CT scan -ventilation perfusion scan(V/Q scan) -pulmonary function test -exercise/skin testing |
|
What is a pulmonary function test(PFT)?
|
evaluates lung function & breathing probs,screening tool,provides very objective data regarding respiratory system
|
|
Endoscopy?
|
allows structures of the respiratory system to be visualized. Must keep your pt NPO after the procedure until a gag reflex has returned.
|
|
3 examples of endoscopy?
|
-bronchoscopy
-laryngoscopy -mediastinoscopy |
|
What is a thoracentesis?
|
aspiration of pleural fluid or air from pleural space.
-check breath sounds after,will get CXR after procedure. |
|
Why might a lung biopsy be done?
|
Bc it provides tissue for histologic analysis,cultures or cytotoxic exam
|
|
What is a common prob of nose/sinuses for pts and what should be done?
|
Epistaxis(nosebleed)
-have pt lean forward w/ pressure on the nose |
|
What is obstructive sleep apnea and why does it usually occur?
|
disruption in breathing that lasts at least 10 seconds & that occurs a minimum of 5x/hr
-usually occurs bc the tongue czs airway obstruction -czs lack of good deep sleep |
|
Dx & Tx of obstructive sleep apnea?
|
-Dx is made w/ sleep study
-Tx:wieght loss,devices that prevent obstruction,CPAP/BiPAP(hold open the airway) |
|
What is chronic airflow limitation? (CAL)
|
a group of chronic lung dzs that includes: asthma(reversible),chronic bronchitis(non-reversible), & pulmonary emphysema(non-reversible)
|
|
What is chronic obstructive pulmonary disease(COPD)?
|
includes emphysema & chronic bronchitis but not asthma. Both are non-reversible lung dzs that cz tissue damage & eventually lead to death.
|
|
Asthma?
|
prob in asthma is that the airflow in the airways becomes obstructed whether due to infl or by constriction of the airways(bronchospasms) or by both these probs
|
|
What is often the trigger for an asthma attack?
|
Inflammation
|
|
Questions to ask when obtaining a history of asthma?
|
-did the adult have asthma as a child?
-does the prob occur seasonally,at night or in response to a specific exposure? -is there a family history? -is the person a smoker or a nonsmoker? |
|
Clinical manifestations of asthma?
|
-may be asymptomatic
-audible wheezes -incr RR -coughing -use of accessory muscles -barrel chest -dyspnea -cyanosis -decr oxygen saturations |
|
What is mild intermittent asthma?
|
symptoms 2x/week or less
|
|
What is mild persistent asthma?
|
symptoms > 2x/wk but not daily
|
|
What is moderate persistent asthma?
|
daily symptoms
|
|
What is severe persistent asthma?
|
continuous symptoms,person has limited activity
|
|
How accurate are pulmonary function tests?
|
-very accurate
-need a baseline |
|
Goals for Tx of asthma?
|
-improve airflow
-avoid things that trigger asthma attacks -active involvement in the case |
|
Meds for Asthma?
|
-bronchodilators
-anti-infl. agents |
|
What do bronchdilators do?
|
improve smooth muscle relaxation w/o any effect on infl.
|
|
2 non medical interventions that may help with asthma?
|
-exercise:important!
-oxygen therapy:useful during exacerbations |
|
What is status asthmaticus?
|
a severe,life threatening acute episode of airway obstruction that gets worse and may not respond to routine tx.
|
|
2 main dzs that comprise COPD?
|
emphysema & chronic bronchitis
|
|
What is emphysema?
|
loss of lung elasticity w/ hyperinflation of lung resulting in dyspnea & incr RR
|
|
What is chronic bronchitis?
|
-usually occurs w/ emphysema
-an infl of the bronchi & bronchioles czed by chronic exposure to irritants. -affects only the airway & not the alveoli -airways become blocked due to prod. of thick mucus |
|
What is the most important risk factor for COPD?
|
smoking. occurs bc the cilia cannot clear the bronchi of mucus,cellular debris & fluid.
|
|
Complications of COPD?
|
-hypoxemia & acidosis:decr O2;incr. CO2
-respiratory inf:due to incr. mucus & decr oxygenation -cardiac failure -other cardiac probs:due to decr O2 |
|
What type of cardiac failure is common in COPD?
|
cor pulmonale:right-sided failure w/o left sided heart failure.
-bc its behind pulmonary circ |
|
What type of history should be done is assessment of a pt w/ COPD?
|
-smoking
-environmental exposure(asbestos,coal mines,post 9/11) -family history |
|
What questions should be asked regarding current probs of pt w/ COPD?
|
-what is the state of breathing
-what triggered the prob -can the pt talk w/o dyspnea -is there a productive cough -have the ADLs been afeected -how does the pt sleep -has the pt lost weight -does the pt have a barrel chest -is there finger clubbing |
|
2 lab tests done in pts w/ COPD?
|
-ABGs: will have a decr O2 & an incr CO2
-PFTs: used to classify COPD 4m mild to severe |
|
Use of O2 w/ COPD?
|
COPD pts that have high levels of CO2 will need low levels of O2 dleivery(1-2L/m) bc their primary drive to breath is the low O2 level. If you give too much O2 they will stop breathing.
*Never give > 2L/m |
|
Ways to improve breathing for COPD pts?
|
-diaphragmatic breathing
-pursed lip breathing -positioning -exercise -energy conservation |
|
Ways to improve secretion removal for COPD pts?
|
-cough
-chest PT & postural drainage -suctioning |
|
Nutrition r/t COPD pts?
|
-need more calories & protein due to incr work of breathing
-nutrition consult -rest B4 meals -small,frequent feedings -may meed bronchodilator prior to feeding -high cal,high protein foods -dietary supplements |
|
5 itises that are common in COPD pts?
|
-rhinitis:infl of nasal mucosa
-sinusitis:infl of sinuses -pharyngitis:infl of mucous mem of pharynx -tonsillitis:infl of tonsil -laryngitis:infl of mucous mem of larynx |
|
What is pneumonia?
|
an excess of fluid in the lungs due to an infl process which is triggered by an inf
|
|
Dz process of pneumonia?
|
-orgs get into airway & mult.
-WBC go to the site of inf & cz capillary leakage,edema &exudate czing inf to spread -fluid collects & interferes w/ gas exchange -alveoli collapse -inf gets into bld stream & spreads |
|
What is 4th leading cz of death in women/5th leading cz of death in men?
|
COPD
|
|
Ppl at risk for community acquired pneumonia?
|
-older ppl
-no pneumonia/flu vaccine -poor overall health/chronic conds -recent exposure to flu -alcohol & tobacco usage |
|
Ppl at risk for nosocomial acquired pneumonia?
|
-older pt
-chronic lung dz -gram neg colonization -altered LOC -aspiration -ET,trachs,NG tubes -poor nutritional state -compromised immune system -meds that incr gastric pH -mechanical ventilation |
|
Clinical manifestations of pneumonia?
|
-look ill:flushed cheeks,anxious,uncomfortable,joint pain
-chest/pleuritic pain -fever,chills -cough w/ sputum prod -tachycardia:weak pulse -dyspnea -tachypnea -congested breath sounds -need to sit up -hypotension |
|
Diagnostic tests for pneumonia?
|
-Lab tests:sputum culture & sensitivity
•CBC •ABGs -radiographic tests:CXR, usually gives Dx -pulse oximetry |
|
Nursing interventions for pneumonia?
|
-cough enhancement
-oxygen therapy -respiratory monitoring -antibiotics |
|
Correct this false statement:
-All diabetics are overweight |
-Type 1 diabetics are usually normal build.
-Type 2 diabetics often overwieight. |
|
Correct this false statement:
-All diabetics are txed w/ insulin. |
-Type 1 are txed w/ insulin.
-Type 2 MAY get insulin but are not exclusively txed w/ insulin. |
|
What type of insulin is cloudy?
|
-NPH insulin is cloudy.
|
|
What is the only type of insulin that can be given IV?
|
Regular insulin.
|
|
Hypoglycemia is most likely to occur at the ____ time of insulin.
|
at the PEAK time
|
|
What is the most common complication of diabetes?
|
heart & cardiac probs
|
|
What decreases a pts need for insulin?
|
Exercise.
|
|
What is the oral diabetic med that should not be given for 48 hours prior to & after procedures using contrast dye?
|
Metformin.
|
|
Should the doc be notified in the case of suspected hypoglycemia?
|
-Check BS, if <60 give OJ or hard candy then check again in 15 min.
|
|
What is diabetes mellitus?
|
deficiency of insulin production or use which czs BS to go up.
|
|
Who might a DM pt be better cared for by?
|
endocrinologist
|
|
What is the goal conc DM?
|
to keep BS as close to normal as possible.
|
|
Environmental Factors r/t DM?
|
-seen more w/ Type 2 as a result of poor eating habits in those that are predisposed.
-weight gain -eating habits |
|
Type 1 diabetes may be AKA?
(older terms) |
-Insulin Dependent DM
-Juvenile Onset diabetes -ketosis prone diabetes |
|
What occurs in Type 1 diabetes?
|
-pancreatic beta cell destruction or defect in beta cell function.
|
|
Why may a defect in beta cell function occur?
|
-may be bc of virus,born that way,etc.
|
|
Etiology of Type 1 diabetes?
|
viral infections
|
|
What do Type 1 diabetics depend on?
|
the administration of insulin.
|
|
When may Type 1 diabetes develop?
|
-usually develops b4 the age of 30 but may develop anytime.
|
|
Clinical presentation for Type 1 DM?
|
rapid clinical presentation. Get sick very rapidly if have incr BS.
|
|
Why are oral agents not effective for Type 1 DM?
|
bc no insulin to be released. Insulin must be admin.
|
|
Tx of Type 1 DM? What % of diabetics are Type 1?
|
tx:insulin,diet & exercise
-10% of diabetics are Type 1. |
|
Old terms for Type 2 DM?
|
-maturity onset diabetes
-non IDDM -adult onset diabetes -ketosis-resistant diabetes |
|
Type 2 is ____ resistant.
|
Insulin resistant. Give meds to stimulate insulin prod. May have insulin but not enough,etc.
|
|
A hx of what incr risk for Type 2?
|
hx of gestational DM
|
|
What type of clinical presentation does Type 2 have?
|
slow clinical presentation.
-90% of diabetics are Type 2. |
|
What is Type 2 commonly txed w/?
|
oral meds
|
|
What is metabolic syndrome(Syndrome X)?
|
group of disorders w/ insulin resistance as the primary prob such as CAD,atherosclerosis,elevated BP.
|
|
What is the epidemiology of Type 2 DM?
|
-chronic dz
-no cure -racial & ethnic diff are seen w/ Type 2 |
|
What is the 7th leading cz of death in the US?
|
Type 2 DM
|
|
Ppl w/ diabetes have many other probs:
|
-2.5x more likely to have a stroke
-leading cz of adult blindness -2-4x more likely to have heart probs -leading cz of end stage kidney probs -80% of lower limb amputations |
|
Complications of DM are _____ but end up being ____ probs.
|
Complications of DM are microvascular(small bld vessels) but end up czing macrovascular probs.
|
|
Pathophysiology of DM?
|
-when a deficiency exists in the amt or activity of insulin, hyperglycemia results.
2 things can happen: *Insulin deficiency can be absolute(Type 1) *Insulin deficiency can be relative(Type 2) |
|
6 steps in DM pathophysiology?
|
1.insulin deficiency czs
2.metabolic prods to build up in the bld & cannot get into cells to be used for energy 3.incr glucose level & impaired fat metabolism 4.cells metabolizing their own glycogen supply & break down protein 5.czs altering of triglycerides,fatty acid & glycerol metabolism 6.ketone bodies are formed |
|
What are the 3 polys of DM?
|
-polyuria
-polydipsia -polyphagia |
|
___ makes ketone bodies & ___ gets rid of them.
|
Liver makes ketone bodies & kidneys get rid of them.
|
|
5 common clinical manifestations of DM?
|
-polyuria
-polydipsia -polyphagia -weight loss -fatigue |
|
What is polyuria?
|
incr urination
-Glucose & water go together. -body is trying to get rid of glucose. |
|
Polyuria occurs bc?
|
occurs bc the kidneys cannot keep up w/ elevated glucose level via glomerular filtration.
|
|
What is polydipsia?
|
incr. thirst
-intense thirst |
|
Why does polydipsia occur?
|
occurs due to water lost w/ polyuria.
|
|
What is polyphagia?
|
-incr hunger
-cells are not being nourished |
|
Why does polyphagia occur?
|
occurs as the cells become starved of food.
|
|
What type DM is weight loss seen w/ and what is it a result of?
|
Seen in Type 1 as a result of:
-glucose loss -calorie loss -body is essentially starving |
|
Why is fatigue seen in DM?
|
-weakness due to lack of nutrients in cells
-cells have no source of energy |
|
Dx of DM in adult men & non-pregnant women?
|
-Random plasma glucose >200 mg/dl + presence of 3 polys & weight loss
-fasting BS > 126 mg/dl on at least 2 occasions -2 hr post-prandial(after you eat) plasma glucose > 200 mg/dl during oral glucose tolerance test |
|
Dx of DM in children?
|
same as adult except w/ added symptom of ketonuria
|
|
What does a hemoglobic A1C reflect?
|
reflects the average BS levels for the 2-3 mo. period B4 the test.
|
|
What is a hemoglobin A1C used for?
|
Used to: 1.eval diabetic tx modalities 2.useful in determining tx for Type 1 diabetics w/ acute ketoacidosis & 3.tracks control of bld glucose in milder cases of diabetes
|
|
The lower the # in hemoglobin A1C the...
|
the better the control.
-Normal 4-6% >8% means person doesn't have good BS control |
|
Causes of hypoglycemia?
|
-unphysiological insulin regimen ex:give food then insulin
-overdosage of insulin or sulfonylureas -inconsistent carb intake -omission of meal -omission of planned snack -uncompensated exercise:when exercise,need less insulin -end stage renal/liver dz -alcohol consumption |
|
Adrenergic S/S of hypoglycemia?
|
-pallor
-diaphoresis -tachycardia:may not have if on beta blocker -piloerection -palpitations -nervousness - |
|
Non adrenergic S/S of hypoglycemia?
|
-sensation of coldness
-weakness -trembling -hunger -irritability -h/a -confusion -circumoral parasthesia -fatigue -incoherent speech -difficulty thinking -behavioral changes -coma -diplopia -emotional liability -convulsions |
|
3 most common S/S of hypoglycemia?
|
-trembling
-irritability -headache |
|
How S/S of hypoglycemia vary?
|
-vary w/ individual
-vary w/ how quickly bld glucose level falls -vary w/ other meds that pt is receiving -may be seen if bld sugar is elevated & then drops(even if BS is still elevated)ex:BS of 800 to 300 |
|
Tx for hypoglycemia?
|
-verify low bld glucose(< 60) w/ a fingerstick if available
-if conscious,give 10-15 g of quick acting carb ex: OJ w/ no sugar added,hard candy -recheck BS in 15 min -repeat if still < 60 -if no fingerstick value available,tx anyway -if unconscious, don't attempt to give anything po -may give 50% glucose IV if in hospital -family may give 1 mg glucagon IM or SC |
|
If pt misses diabetic oral med & normally takes pills twice a day, when may they take their missed pill?
|
may take their missed pill w/in 3 hrs of the time it should have been taken.
-If its been > 3 hrs, wait for next scheduled dose -DON'T take a double dose |
|
If pt is on a long acting sulfonylurea taken once a day & misses dose, what can they do?
|
can take their med if they are w/in 12 hrs of their missed dose.
-otherwise wait until next scheduled time -DON'T take double dose |
|
What does the strength of insulin refer to?
|
-refers to the # of units of insulin/mL
|
|
What is the most common strength?
|
U-100
|
|
What type of insulin needs a special RX to be obtained?
|
U-500
|
|
What type of insulin may still be available but is not normally utilized?
|
U-40
|
|
Insulin differs in?
|
-Onset:the speed of the effect
-Peak:the time of greatest action -Duration:the length of time they act |
|
Action of Insulin?
|
-all types lower BS
-must coordinate insulin action w/ dietary carb & activity so that: *insulin is available for optimal metabolism when the food that was eaten is absorbed *food is available while insulin is acting to prevent hypoglycemic rxns |
|
Principles to use when coordinating food & insulin?
|
-carb intake must be coordinated w/ insulin action
-regular or quick action insulin requires a supplemental snack of 15g of carbs to match the peak action of the insulin. *i.e. 3 hrs after insulin admin *regular insulin given at 6 pm; pt should get a snack around 9 pm |
|
Name the rapid acting insulins.
|
-Lispro(Humalog)
-Aspart(Novolog) *have food in the room |
|
Onset,Peak & Duration of rapid acting insulins.
|
Onset:15 min.
Peak:30 min-1.5 hrs Duration:3-4 hrs |
|
Name the insulin that is short acting.
|
Regular.
-clear in color. -watch for insulin rxn during peak time |
|
Onset,Peak & Duration of Regular insulin?
|
Onset:30 min
Peak:2-4 hrs Duration:6-8 hrs. |
|
Name the intermediate-acting insulins.
|
NPH,N & Lente
|
|
Onset,Peak & Duration of intermediate acting insulins?
|
(NPH,N,Lente)
Onset:1.5 hrs Peak:4-1 hrs Duration:28 hrs |
|
What insulins are cloudy in color?
|
-NPH
-N -Lente -Ultralente -Combination |
|
Name the long-acting insulins.
|
-Ultralente:used like a baseline
-Lantus |
|
Onset,Peak & Duration of Ultralente?
|
Onset:4-6 hrs
Peak:8-20 hrs Duration:28 hrs |
|
Onset,Peak & Duration of Lantus?
|
Onset:1-3 hrs
Peak: No peak Duration: 24 hrs |
|
Can Lantus be given in combo w/ other insulins?
|
Cannot be given in combo w/ other insulins; must use separate syringe.
|
|
2 types of combo insulin?
|
70/30
75/25 -a mixture of R & NPH or Humalog & NPH |
|
Onset,Peak & Duration of combination insulin?
|
Onset:30 min
Peak:2-12 hrs Duration:24 hrs |
|
What does a 2 dose insulin protocol mean?
|
combo of short acting insulin given b4 breakfast & dinner
|
|
What does a 3 dose insulin protocol mean?
|
combo of short & intermediate acting insulin given b4 breakfast,before dinner & at bedtime.
|
|
What does a 4 dose insulin protocol mean?
|
short acting insulin given b4 meals & at bedtime
|
|
Sliding scale?
|
-finger scale is usually done every 4-6 hrs(before meals) & before bed.
-R insulin is given after hyperglycemia occurs -used very frequently in the hospital |
|
When is finger stick done every 4 hrs for sliding scale?
|
every 4 hrs if eating
|
|
When is finger stick done every 6 hrs for sliding scale?
|
-if on TPN or
hyperalimentation: <- bc of high sugar content |
|
About insulin pumps?
|
-continuous subQ insulin infusion pumps w/ incr insulin @ meal time
-provides for the most normal delivery of insulin -mimics the action of the pancreas in a non-diabetic person -pump is programmed to deliver varying amts of insulin hourly |
|
Advantages of insulin pumps?
|
-most physiologically normal delivery system
-elicits better control -allows for more independence |
|
Disadvantages of insulin pumps?
|
-initial cost of approx $5000 for pump
-needle SQ placed in abdomen all the time -risk for rapid-onset DKA if there is interruption of insulin delivery |
|
Which site has fastest absorption of insulin?
|
fastest absorption in abdomen followed by arms,legs & buttocks.
-should use same site for each timed inj.(i.e. abdomen for morning inj always,arms for dinner,etc.) |
|
What does rotation of insulin inj sites help prevent?
|
helps prevent lipohypertrophy(incr fat deposits in skin) or lipoatrophy(loss of fatty tissue)
|
|
What is the goal of nutritional mgmt for diabetics?
|
to maintain reasonable weight,control bld glucose & lipid levels w/o czing other health probs
|
|
What is the exchange system for diabetics based on?
|
based on carbs, meat, fat
|
|
6 exchange lists of the diabetic exchange system?
|
-starch/bread
-meat/meat substitutes -veggies -fruit -milk -fat |
|
What is carbohydrate counting?
|
-simple approach to meal planning
-uses total grams of carbs 4m food package |
|
4 ADA approved non-nutritive sweeteners?
|
-saccharin
-aspartame -acesulfame K -sucralose |
|
3 types of home bld glucose monitors?
|
-accucheck
-lifescan -onestep |
|
Self monitoring for Type 1?
|
-should check BS before meals & at bedtime
-often 4 times/day |
|
Self monitoring for Type 2?
|
frequency depends on pt
|
|
What should both groups of DM do conc self monitoring?
|
-individuals should keep a log book so that they can manipulate insulin,diet & exercise independently
|
|
Self monitoring of urine?
|
-ketones should be tested for BS readings > 300 mg/dL
-presence of ketones in the urine is a dangerous sign |
|
Self monitoring conc capillary readings?
|
-works like a pulse oximeter
-painless -not as accurate -used in Europe |
|
Exercise acts as an?
|
insulin sensitizer allowing insulin doses to be decr.
|
|
Exercise allows?
|
glucose uptake by the skeletal muscle
|
|
Benefits of exercise r/t DM?
|
-improves insulin sensitivity
-lowers BS during & after exercise -improves lipid profile -may improve some HTN -assists w/ weight loss -promotes cardiovascular fitness -improves sense of well-being |
|
DM pt education & exercise?
|
-check BS before,during & after exercise
-may need a stress EKG if over 35 -don't exercise if BS > 250 mg/dL or if ketones present in urine -may need to lower insulin dose |
|
Sick days r/t DM?
|
-bs usually goes up when one is sick
-person must continue to take their diabetic meds -try to continue to eat food in normal meal plan(N/V) -if individual cannot eat at all, call MD -drink lots of water or sugar-free liquids |
|
Hyperglycemia after surgery leads to?
|
impaired wound healing & a hypercoagulable state(thrombus)
|
|
Ways to min probs for diabetic pts conc surgery?
|
-good control prior to surgery
-schedule early in am -regular schedule of food,insulin,etc. until the night b4 surgery -start IV w/ dextrose b4 surgery -give 1/2 dose of intermediate acting insulin b4 surgery -should check BS b4 long procedures -IV after surgery -divide normal dose of insulin over 24 hrs after surgery -use algorithm & finger stick for extra insulin after surgery |
|
Most insulin can be mixed into 1 syringe w/ the exception of?
|
Glargine insulin
|
|
Order for mixing insulin?
|
Clear to Cloudy or R to N
|
|
Eye problem complications r/t DM?
|
-damage to small bld vessels in the eyes
-vessels rupture -blurred vision(spider web) -blindness -yearly eye exams(encourage) -control BS -no smoking |
|
Kidney problems r/t DM?
|
-affects small bld vessels in the kidneys leads to
-kidneys not able to filter out wastes -decr prod in urine -#1 reason for dialysis -symptoms are late to appear -early clinical signs of probs:microalbuminuria test annually |
|
Heart problems r/t DM?
|
-bld vessels in the heart are damaged due to incr BS
-vascular system is damaged -incr risk for heart attacks(leading cz of death) -metabolic syndrome -eat low-fat foods -get regular exercise -control BP -don't smoke -control BS |
|
Skin & Foot probs r/t DM?
|
-nerve damage
-circ probs -sores & cuts may not heal well(often) -protect feet & skin -bathe feet daily -check feet for blisters,red spots & cuts -call the doc if any sores don't heal w/in 2 days -call the doc if there are any S/S of inf. -always wear shoes |