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343 Cards in this Set

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What is the pre-operative phase?
the time the decision is made to have surgery until the pt is transported into the operating room.
Wht is minimal invasive surgery?
aka bloodless surgery
-done through fiberoptics,recovery time less
What type of surgery involves little risk to life?
minor surgery
What type of surgery may involve risk to life and where is it usually performed?
major surgery.
-usually done in hospital
What are 6 general types of surgery?
-diagnostic
-curative
-restorative
-palliative
-cosmetic
-ablative
What is a diagnostic surgery for?
to determine the cz of the symptoms
What is a curative surgery for?
to remove a diseased part
What is a restorative surgery for?
strengthens a weakened part
ex: total knee replacement
What is a palliative surgery for?
relieves the symptoms w/o curing the dz.
ex: colostomy to remove bowel obstruction when have cancer
What is a ablative surgery for?
excises tissue that may contribute to or worsen the pt's existing med. cond.
How does the sympathetic nervous system respond to surgery?
there is an incr amt of norepinephrine secreted that results in peripheral vasoconstriction.
What does peripheral vasoconstriction help maintain during surgery?
helps maintain BP during surgery by maintaining fluid vol w/ bld loss in surgery.
-may decr urinary output for about 24 hrs.
Surgery may also cz an increase in aldosterone secretion which results in what?
decreased GI activity and sodium retention.
What is the hormonal response to surgery and what does it result in?
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.
What hormone has incr secretion during surgery that helps to maintain bld volume?
anti-diuretic hormone.
What is the metabolic response to surgery?
an incr in carbohydrate metabolism,fat metabolism, & protein metabolism.
6 factors that affect pt's response to surgery?
-age
-meds
-medical history
-prior surgical experience
-health/family history
-type of surgery planned
How can age affect a pt's response to surgery?
-very old & very young likely to have more complications
-cardiovascular changes w/ aging
-respiratory changes w/ aging
How can meds affect a pt's response to surgery?
-tobacco use: incr incidence of pulmonary complications
-Rx drugs
-illegal drugs:react to anesthesia diff.
-OTC drugs
How do bronchodilators work?
work by stimulating the beta2-adrenergic receptors allowing the smooth muscles of the bronchi to relax.
What do beta2-adrenergic receptors do?
cz vessels to relax.
Do bronchodilators have any effect on the inflammatory process?
No.
3 examples of bronchodilators?
-beta2 agonists
-cholinergic antagonists
-methylxanthines
What do beta2 agonists bind to?
bind to the beta2 adrenergic receptors.
When beta2 agonists bind to the beta2 adrenergic receptors it czs an incr in?
czs an incr in the intracellular level of cAMP resulting in relaxation of the smooth muscle.
What does cAMP stand for?
cyclic adenosine monophosphate
Are beta2 agonists short or long acting?
can be short OR long acting
What type of relief do short acting beta2 agonists provide?
provide rapid but short term relief.
-Medication is delivered directly to the prob w/ minimal side effects
When are short acting beta2 agonists most effective?
most effective if used at the beginning of an attack or if an attack is anticipated.
Most commonly used short acting beta2 agonist?
Albuterol
How can short acting beta2 agonists be administered?
either as a metered dose inhaler(MDI) or as a dry powder inhaler(DPI)
Side effects of short acting beta2 agonists?
-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
Where do long acting beta2 agonists deliver the med to?
directly to the bronchioles.
Long acting beta2 agonists are best used for?
better used for prevention of attack
2 examples of long acting beta2 agonists?
-salmeterol(Serevent)
-formoterol fumarate(Foradil Aerolizer)
What are cholinergic antagonists aka?
anticholinergic agents
-dry things up(especially czs dryness in mouth)
How do cholinergic antagonists work?
work by blocking the parasympathetic nervous system so that sympathetic nervous system takes over czing bronchodilation & decr pulmonary secretions.
How long acting are cholinergic antagonists?
usually short acting
How often must cholinergic antagonists be used?
must be used several times a day.
Example of a cholinergic antagonists?
ipratropiun(Atrovent)
When are methylxanthines used?
used when the other drugs don't work
How are methylxanthines administered?
administered systemically, have side effects & narrow therapeutic ranges.
2 examples of methylxanthines?
theophylline(Theo-Dur) & aminophylline(Truphylline )qZ
How are aminophylline drips given?
have to be given by infusion pump.
-also has more side effect
Why do you need to monitor pts blood level when administering methylxanthines?
bc they have a narrow therapeutic range which may be very close to what is needed to cz bronchodilation.
What should theophyllin level be when pt taking methylxanthines?
theophylline level should be 10-20
What are the signs of methylxanthine toxicity?
N/V/D:especially nausea,early sign of toxicity
-tachycardia
-dysrhythmias
-restlessness
What potentiates side effects of methylxanthine?
Caffeine
How are antiinflammatory agents given?
systemically or by inhalation
5 examples of anti-inflammatory agents?
-corticosteroids
-inhaled anti-inflammatory agents
-mast cell stabilizers
-monoclonal antibodies
-leukotriene antagonists
What do corticosteroids do?
decrease inflammation by preventing the synthesis of mediators
How can corticosteroids be given?
as an inhaler or systemically
Inhaled corticosteroids may help to?
may help to prevent symptoms
2 examples of corticosteroids?
fluticasone(Flovent) & budesonide(Pulmicort)
Side effect of corticosteroids?
make the pt susceptible to oral infections
Why are systemic corticosteroids only used for severe problems?
bc they have serious side effects
What do inhaled nonsteroid anti-inflammatory agents do?
inhibit the release of inflammatory mediators 4m respiratory cells & WBCs
Do inhaled nonsteroid anti-inflammatory agents reverse attacks?
No. prevents attacks more than reverses them.
How often must inhaled nonsteroid anti-inflammatory agents be used?
must be used on a regular basis even if there are no symptoms.
Example of inhaled nonsteroid anti-inflammatory agent?
nedocromil(Tilade)
What do mast cell stabilizers prevent?
prevents the mast cell membranes from opening when an allergen binds to IgE.
Do mast cell stabilizers reverse attacks?
No. Helpful in the prevention of attacks more than reversing an attack.
Example of a mast cell stabilizer?
(Intal)
How do monoclonal antibodies work?
work by binding with IgE receptors sites on mast cells & basophils preventing allergens 4m releasing mediators 4m the mast cells & basophils.
What is a monoclonal antibody helpful for conc. asthma attacks?
more helpful in the prevention of attacks then during the attack
Example of a monoclonal antibody?
omolizumab(Xolair)
How do Leukotriene antagonists work?
work by either preventing leukotriene synthesis or blocking the leukotriene receptors
How are leukotriene antagonists given?
orally
2 examples of leukotriene antagonists?
-zafirlukast(Accolate)
-montelukast(Singulair)
What should be monitored if a pt is on Singulair?
liver function tests
What type of meds are used for pneumonia?
anti-infectives are used for all types of pneumonia unless czed by a virus
5 common anti-infectives used for pneumonia?
-Azithromycin
-Levofloxacin
-Ticarcillin
-Vancomycin
-Ciprofloxacin
How can your medical/cardiac history affect the pt's response to surgery?
-may need med clearance lots of times
-many times pulmonary,cardio,renal, & endocrine systems must be evaluated
How can previous surgery/anesthesia affect the pt's response to surgery?
may have had a good or bad outcome that affects their feelings towards surgery
-also will let you know feelings towards anesthesia, allergies, etc.
How can family history affect a pt's response to surgery?
may have a family hx of malignant hyperthermia
Why is a pre-operative assessment done?
to establish a baseline
General things that will be assessed in a Pre-operative assessment?
-vital signs
-allergies
-cardiovascular system
-respiratory system
-renal/urinary system
-neurological system
-musculoskeletal system
-nutritional status
What type of cardiovascular assessment will be done pre-operatively?
-check for hypertension
-assess heart rate,rhythm,sounds
-look for edema
-assess the peripheral vascular system
What type of respiratory assessment is done pre-operatively?
-assess breath sounds
-look for lung expansion
-evaluate overall respiratory effort
-look for clubbing of fingers
What type of renal/urinary assessment is done pre-operatively?
-look at BUN & creatinine
-monitor F & E status
-I & O
What type of neurologic assessment is done pre-operatively?
-overall mental status
-assess for falls risk
What type of musculoskeletal assessment is done pre-operatively?
-Will mobility be an issue?
What type of nutritional assessment will be done pre-operatively?
-malnutrition
-obesity
What type of lab data will be done pre-operatively?
-blood tests(CBC:hemoglobin,hematocrit,WBC,RBC)
-urinalysis
-x-rays:some hosp require CXR,EKG if pt over a certain age
-other
What does a signed consent imply?
implies that the client has the knowledge to understand the nature of the surgical procedure as well as the possible consequences.
What is the order in which consent is obtained if an adult is unable to do so?
-spouse
-adult child
-parent
-sibling
How can consent be given in an emergency?
can be given over the phone(have 2 ppl listen)
-or faxed
What questions might you ask to assess a pt's psychological readiness for surgery?
-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?
What objective data can you look for r/t preparedness for surgery?
-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
What type of medical interventions may be carried out prior to surgery?
-diet: will want to know when last ate or drank
-bowel cleansing:for bowel surgery
-skin prep:shaves uncommon. will clip sometimes
What is the goal of pre-op teaching?
to decrease anxiety
What should pre-op teaching include?
what to expect during the surgical experience
What does the amt of info in the pre-op teaching depend on?
patients:
-background
-interest
-stress level
-age
What should be taught concerning pre-operative tests?
reason for and an explanation of
What should be taught conc. pre-op routines?
about NPO,prep,enema,etc.
What information should be given to the family pre-operatively?
-where they should wait
-where the surgeon will talk to them
-how long it will be
What type of final assessment will be done on the day of surgery?
-vs
-ID band
-Bld band
-labs/tests
-nail polish off
-gown on
-bladder emptied
Some reasons for pre-op meds to be given on the day of surgery?
may be given prior to surgery to decr anxiety,provide sedation,induce amnesia,decr saliva
Why may narcotics be given pre-operatively?
to reduce anxiety and promote relaxation but may depress resp, circulation,& GI motility
2 examples of narcotics that may be given pre-operatively?
-demerol
-morphine
Why may barbiturates be given pre-operatively?
to reduce anxiety,promote relaxation & sleep but cz excitement or confusion in elderly.
2 examples of barbiturates that may be given pre-operatively?
-Nembutal
-Seconal
Why may benzodiazepines be given pre-operatively?
to reduce anxiety & promote relaxation but cz dizziness & headache.
2 examples of benzodiazepines that may be given pre-operatively?
-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
Example of a neuroleptanalgesic that may be given pre-operatively?
Fentanyl
When should pt be ID'ed before sugery?
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.
When does the Intra-operative phase begin and end?
begins when the pt is transferred to the operating table and ends w/ the transfer to the recovery room.
What is the holding area?
-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?
-scrub nurse/tech
-circulating nurse
-anesthesiologist or CRNA
-surgeon
-second surgeon
-others:student nurse,orthopedic rep,etc.
What are common duties of the circulating nurse in the surgical team?
-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
Responsibilities of scrub nurse/tech?
-prepares sterile supplies & equipment
-assists the surgeon
-accounts for equip.
Upon arrival of pt in the OR the circulating nurse should?
-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.
Responsibilities of Anesthetist/CRNA?
administration of the anesthetic agents
Effects of anesthesia?
-amnesia
-analgesia
-hypnosis
-relaxation
4 types of anesthesia?
-general
-regional
-local
-conscious
What is general anesthesia?
may be given IV or by inhalation. Blocks the awareness centers in the brain producing unconsciousness,body relaxation,& loss of sensation.
What is regional anesthesia?
analgesia that occurs over a specific body area. May be given via spinal,Bier block,epidural. Pt is conscious.
What is local anesthesia?
analgesia given over a limited tissue area. Pt is conscious.
Important considerations for spinal anesthesia?
-a type of regional anesthesia
-usually done on the lower ext.
-pt remains awake during the procedure
-Headache is a common post anesthesia prob
What should be done if pt has a headache post anesthesia?
-keep the pt supine
-force fluids if allowed
What is conscious sedation?
-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
What is malignant hyperthermia?
-a life threatening complicaton triggered by the anesthetic agent. Only occurs in pts w/ an inherited defect in the membrane of the skeletal muscle.
What levels rise in pts body during malignant hyperthermia?
the pt's calcium level rises & metabolic rate incr dramatically.
What may happen to pt if calcium level & metabolic rate is allowed to incr during malignant hyperthermia?
pt may develop renal failure,DIC(clotting prob),neurological damage, & heart failure.
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?
-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
Upon arrival in PACU?
-circulating nurse will give report to PACU nurse
-PACU nurse will do quick assessment
What will the quick assessment that the PACU nurse does contain?
-assessment of airway
-vital signs
-LOC
-EKG
A more detailed report from the circulating nurse to the PACU nurse should include?
-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
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
Why is a pharyngeal airway not tolerated in a conscious pt?
bc it may stimulate vomiting or a laryngospasm
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
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.
When should oxygen be given until post op?
until pt is conscious,can take deep breaths on their own or as determined by bld gases or O2 sats(keep bw 92-98%)
Circulatory complications occur post op due to?
hypotension & cardiac dysrhythmias:reason why VS are assessed so frequently in the PACU.
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.
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