EXAM 2 - Nursing Theory N12 Cabrillo College (3/3) Questions & Answers correct

EXAM 2 - Nursing Theory N12 Cabrillo College (3/3) Questions & Answers correct What are the different classifications of surgery? - Serious : Major (extensive reconstruction/alteration; increased risk), to minor (minimal alteration, correction of deformities, decreased risk) - Urgency: Elective, urgent (necessary for pt health, prevention of additional problems), emergent (immediately to save life/function of body part) - Purpose: Diagnostic, ablative, palliative, reconstructive/restorative, procurement for transplant, constructive, cosmetic What are some surgical risk factors - Smoker - Age (very young/very old) - Mal-nutrition - Obesity - Obstructive Sleep Apnea (OSA) - Immunosuppression - Fluid/electrolyte imbalance - Postoperative nausea/vomiting (PONV) - Venous Thromboembolism (VTE) What does glycemic control have to do with infection? Poor glucose control increases risk for wound infection/mortality Pressure ulcer prevention aids - Positioning - Pressure-relieving surfaces What is the importance of warfarin (coumadin) in surgery? Warfarin is a blood thinning medication and must be ceased 24-48 hrs pre-op What allergies should be assessed pre-op? - Medications - Topical agents - Latex - Food What are the phases of preop? ADPIE - Assessment (pt history: medical/surgical, psychological; Risk factors; Medications; Allergies; Smoker; Substance abuse; Pregnancy; Knowledge r/t surgery; Support; Cultural/spiritual factors; Physical exam; N. diagnosis) - Planning (Goals & Outcomes; Setting priorities) - Implementation (Informed consent; Privacy; Health promotion; Post-op activity; Pain-Relief; Rest; Acute Care) - Evaluation What are some of the tasks of the PCU nurse? PCU - Preanesthesia Car Unit - Inserts IV cath (if not already present) - Administers preop meds - Monitors Vitals - Inserts Urinary Cath (can also happen in OR) What are the Intraoperative Phases - Surgical Phase - Implementation - Evaluation Intraoperative surgical phase: implementation: Aspects of Acute Care Acute Care - Physical prep - Intraoperative warming - Latex sensitivity/allergy - Positioning of pt for/during surgery - DOCUMENTATION Intraoperative surgical phase: implementation: Types of anesthesia - General Anesthesia: pt is unconscious, feels nothing - Regional anesthesia: Pt is awake, parts of body are asleep - Moderate (conscious) sedation: Depressed level of consciousness; Versed/Fentanyl Nursing roles during surgery? - Circulating nurse - Scrub Nurse - Registered nurse First Assistant What is the role of the Circulating Nurse in the OR? - Remains unscrubed - Uses the nursing process in the mngmnt of pt care activities in OR suite - Manages pt positioning, antimicrobial skin preparation, medications, implants, placement and function of IPC devices, specimens, warming devices, and surgical counts of instruments and dressings - Ensures safety by minimizing risk/error - Ensures cost efficient use of supplies What is the role of the RN First Assistant in the OR? RN first assistant (RNFA) - Requires formal academic education - Collaborates w/surgeon by handling and cutting tissue, using instruments and medical devices, providing exposure of the surgical area and hemostasis, and suturing What is the role of the scrub nurse in the OR? - Often certified (CST) - The scrub nurse must have a thorough knowledge of each step of a surgical procedure and the ability to anticipate each instrument and supply needed by the surgeons - Ensures safety by minimizing risk/error - Ensures cost efficient use of supplies Define Malignant Hyperthermia - Hereditary condition of hypermetabolic state, uncontrolled heat production. Occurs when susceptible people receive certain anesthetic drugs - Life Threatening - - increased intracellular Ca ion conc; increased CO2levels; metabolic/respiratory acidosis; increased O2 consumption; prod of heat; activation of sympathetic nervous sistem; High serum K levels; mulitple organ dysfunct/failure What are early signs/symptoms of malignant hyperthermia? Later signs/symptoms? - elevated temperature - tachypnea - tachycardia/arrhythmias - hyperkalemia/hypercalcemia - hypercarbia - muscular rigidity - Elevated temperature - myoglobinuria - multiple organ failure What are the phases of postoperative care? - Phase I : immediate postop recovery - Phase II: recovery - Phase III: convalescence What happens in phase I of postoperative care? - Notification/arrival - Hand off: OR to PACU - Pt monitoring/assessment: Modified aldrete score; modified postanesthesia recovery score (PARS); DASAIM discharge assessment tool - Discharge & Hand-off: PACU to acute care What happens in phase II of postperative care? - Recovery in ambulatory surgery - Postanesthesia Recovery Score (PARS) What happens in phase III of postperative care? - Nursing process ADPIE - Assessment: - Diagnose any discrepancies - Planning - Implementation - Evaluate What would you assess post operatively (phase III) ASSESS: - through pts eyes - airway & respiration - circulation - temp control - fluid/electrolyte balance - neurological functions - skin integrity/condition of wound - metabolism - genitourinary function - gastrointestinal function - comfort What kind of planning should happen post operatively (phase III) PLANNING - Goals & Outcomes (continue into home setting; established during the preop phase that are still relevant) - Setting priorities (Reestablish priorities as status of pts probs change/evolve) - Teamwork/Collaboration (Goal: return pt to best poss. level of health/functioning, w/smooth transition to home, rehab, or long-term care) What kind of implementation would you consider in phase III of postoperative care? IMPLEMENTATION - Acute Care - Maintain respiratory function - Prevent circulatory complications (thrombus formation): leg exercises; OOB - Achieving rest/comfort - Temperature regulation - Maintain neurological function - Maintain fluid/electrolyte balance - Promote normal GI funct & adequate nutrition - Promote urinary elimination - Skin & wound care - Maintain/enhance self-concept - Restorative & Continuing Care - Prep for discharge - Provide pt ed - Help pt adhere to exercise program(s) - Make referrals to home care PRN How would you evaluate in phase III of post operative care Thru pts eyes: Have expectations been met? Pt outcomes - Evaluate for pain relief - Evaluate pt self-care measures Signs and symptoms of fluid imbalance - Dehydration - Dizziness - Confusion - Electrolyte imbalance - irregular heartbeat; fast heart rate; fatigue/lethargy; convulsions/seizures; nausea/vomiting; diarrhea/constipation - Altered elimination Signs & symptoms of hemorrhage - BP drop 90/60 - Increased HR 100 - Cool, clammy skin - Weak distal pulse - Decreased capillary refill - Diminished orientation/LOC - Severe headache - Nausea a vomiting common - Onset rapid, deterioration rapid Symptoms of Hypoxia - Skin color changes (blue or bright red) - Tachycardia/Arrhythmias - Increased respiratory rate - Open-mouthed / dyspenic breathing - Shortness of breath - Slowing Heart Rate - Cold extremities - Sweating - Anxiety, Confusion, Drowsiness Nurse's role in obtaining informed consent INFORMED CONSENT REQUIRED FOR SURGERY - Assess and document - Review rights of minors - Develop therapeutic relationship - Verify prior consent - Serve as witness *IF pt confused about procedure/has Qs: call MD - Report ANY concerns about pt understanding of surgery to operating surgeon/anesthesia provider (in regards to surgical procedures): When would coughing/deep breathing be potentially contraindicated? After brain, spinal, head, neck, or eye surgery What position is best for Bariatric pts to attain improved lung function/vital capacity? Reverse Trendelenburg or side-lying position What are the phases of wound healing? - Inflammatory phase - Proliferative phase - Maturation phase Explain the inflammatory phase of wound healing How long is it? Stages? - Occurs w/in Minutes - (lasts up to) 3 days - Hemostasis - Injured tissue releases substrates - Increased capillary permeability - Epithelialization starts - Leukocyte infiltration w/in a few hrs - Prostaglandins release during injury (- pain) What happens during hemostasis of the inflammatory stage? What does injured tissue trigger release of? - Hemostasis: vessels constrict, platelets activate, fibrin matrix forms - Injured tissues release substrates: histamine, serotonin & bradykinin - vasodilation, Increased blood supply (redness & heat) - leads to increased capillary permeability (fluid shifts from intravascular to interstitial compartment: edema, pain & functional impairment) - Epithelialization starts What happens during Leukocyte infiltration phase of the inflammatory stage? When does it occur? What is released during injury that causes pain? - Leukocyte infiltration occurs w/in a few hrs - Neutrophils ingest bacteria (Die in a few days, leaving behind enzyme exudate) - Monocyte - magrophage, phagocytosis (Clears the wound of debris; stimulates formation of fibroblasts; Releases growth hormones) - Fibroblasts synthesize collagen - Epithelial cells move from wound margins inward (cover area w/in 48 hrs) - Prostiglandins released during injury What happens if there is too much or too little inflammation in inflammatory phase of wound healing? (compounded by?) TOO MUCH: - arriving cells compete for limited nutrients TOO LITTLE - Healing is slowed (compounded by steroids, immunocompromization, chemotherapy, rheumatoid arthritis treatments) What are the stages of the proliferative phase of wound healing? How long does it last? 3 - 24 days - New connective tissue, granulation - Collagen synthesis is created by fibroblasts - Angiogenesis - Epithelialization What is epithelialization Process of creating new skin tissue in the various layers of damaged skin