NUR265: Exam 1 (Fall questions fully solved & updated .

17.2 Describe a comprehensive prep assessment to identify pertinent health and surgical risk factors health hx and physical exam medications and allergies nutritional, fluid status dentition drug or alcohol use respiratory and cardiovascular status hepatic and renal function endocrine function immune function previous medication use psychosocial factors spiritual and cultural beliefs 17.3 Describe considerations related to prop nursing care of older adult pts, pts who are obese, and pts with disabilities -cardiac reserves are lower -renal and hepatic functions are depressed -gastrointestinal activity is likely to be reduced -respiratory compromise -decreased subcutaneous fat; more susceptible to temp changes -may need more time and multiple explanations to understand and retain what is communicated restrictions -Elderly: increased risk for infection and wound changes, more physiological changes, increased risk for a variety of medical conditions, nutritional status (loss of muscle mass), fall risks/injuries, more meds -Obese: hypertension, increased risk of infection (more tissue), mobility, airway, diabetes, wound healing, dehiscence (wound opening up) -Disabilities: depending on disability (mobility, visual, hearing) Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0:00 / 0:15 Full screen Brainpower Read More 17.4 Identify legal and ethical considerations related to obtaining informed consent fo r surgery -should be in writing before non emergent surgery -legal mandate -surgeon must explain the procedure, benefits, risks, complications, etc. -nurse clarifies info and witnesses sig -consent is valid ONLY when signed before administering psychoactive premedication -consent accompanies pt to OR 17.5 Describe pre op nursing measures that decrease one the risk for infection and other postop complications -providing pt education -deep breathing, coughing, and incentive spirometry -mobility and active body movement -pain management -cognitive coping strategies -education for pts undergoing ambulatory surgery -provide psychosocial intervention: reducing anxiety and decreasing fear, respecting cultural/spiritual/and religious beliefs -maintaining pt safety -managing nutrition, fluids -preparing the bowel -preparing the skin -pt changes in gown, mouth inspected, jewelry removed, valuable stored in a secure place -administering preanesthetic medication -maintaining prep op record -transporting pt to presurgical area -attending to family needs 18.2 Specify the principles of surgical asepsis surgical environment -unrestricted zone: street clothes allowed -semi restricted zone: scrub clothes and caps -restricted zone: scrub clothes, shoe covers, caps, masks surgical asepsis environmental controls 18.4 Identify adverse effects of surgery and anesthesia -anesthesia awareness -nausea, vomiting, anaphylaxis -=hypoxia, respiratory complications -hypothermia -malignant hyperthermia -infection -allergic reactions, drug toxicity or reactions -cardiac dysrhythmias -CNS changes, over sedation, undersedation -trauma: laryngeal, oral, nerve, skin, including burns -hypotension -thrombosis 19.1 Describe the responsibilities of the post-anesthesia care nurse in the prevention of immediate postoperative complications -provide care for pt until pt has recovered from effects of anesthesia ---resumption of motor and sensory function ---oriented ---stable VS ---shows no evidence of hemorrhage or other complications of surgery -vital to perform frequent skilled assessment of pt -review pertinent info, baseline assessment upon admission to unit -asses airway, resp function, cardiovascular function, skin color, LOC, and ability to respond to commands -reassess VS, pt status every 15 mins or more frequently as needed -administration of postop analgesia -transfer report, to another unit or discharge pt to home -discharge planning, discharge assessment -provide written, verbal instructions regarding follow-up care, complications, wound care, activity, meds, diet ---give to pt, responsible adult who will accompany pt -give prescriptions, phone numbers ---discuss actions to take if complication occur -pt are not to drive home or be discharge home alone ---sedation, anesthesia may cloud memory, judgement, affect ability 19.3 Identify common post-op problems and their management -pulmonary infection/hypoxia -DVT/PE -hematoma/hemorrhage -infection -wound dehiscence or eviseration -VTE/PE -incentive spirometer -raise HOB -reposition -supply 02 -encourage coughing and deep breathing -jaw thrust -pneumonia -actealesis 19.7 Identify assessment parameters and interventions appropriate for the early detection of post-op complications -resp, pain, mental status/LOC, general discomfort -maintain a patent airway -maintain cardiovascular stability -indicators of hypovolemic shock/hemorrhage -relieving pain and anxiety -controlling nausea and vomiting -gerontologic considerations 13.2 Describe the role of the kidneys, lungs, and endocrine glands in regulating the body's fluid composition and volume Kidneys -vital to the regulation of fluid and electrolyte balance, 180L of plasma a day in an adult, excrete 1-2L of urine Lungs -remove water vapor (insensible loss) approx 300 mL of water daily in a normal adult Endocrine Glands -Pituitary: hypothalamic manufactures ADH which is stored in the posterior pituitary gland and released as needed to conserve water -Adrenal: aldosterone--causes sodium rendition (water retention) and potassium loss, cortisol--produce sodium and fluid retention -Parathyroid: regulate calcium and phosphate balance by means of parathyroid hormone 13.3 Identify the effects of aging on fluid and electrolyte regulation -clinical manifestations of imbalance may be subtle -fluid deficit may cause delirium -decreased cardiac reserve -reduced renal function -dehydration is common -age-realted thinning of the skin and loss of strength and elasticity 13.4 Plan effective care of pts with the following imbalances: Fluid Volume Deficit (Hypovolemia) -I&O at least every 8 hrs, sometimes hrly -daily weight -VS closely monitored -skin and turgor, mucosa, urine output, mental status -measure to minimize fluid loss -administration of oral fluids -administration of parenteral fluids 13.4 Plan effective care of pts with the following imbalances: Fluid Volume Excess (hypervolemia) -I&O and daily weights, assess lung sounds, edema, other symptoms -monitor responses to medication--diuertics and parenteral fluids -promote adherence to fluid restrictions, pt teaching related to sodium and fluid restrictions -monitor, avoid sources of excessive sodium, including medications -promote rest 13.4 Plan effective care of pts with the following imbalances: Sodium Deficit (hyponatremia) -treat underlying condition -sodium replacement -water restriction -medication -assessment: I&O, daily weight, lab values, CNS changes -encourage dietary sodium -monitor fluid intake -effects of meds (diuertics, lithium) 13.4 Plan effective care of pts with the following imbalances: Sodium Excess (hypernatremia) -gradual lowering of serum sodium level via infusion of hypotonic electrolyte solution -diuretics -assessment of abnormal loss of water and low water intake -assess for OTC sources of sodium -monitor for CNS changes 13.4 Plan effective care of pts with the following imbalances: Potassium Deficit (hypokalemia) -potassium replacement: increased dietary sodium or IV for severe deficit -monitor for ECG for changes -monitor ABGs -monitor pts receiving digitalis for toxicity -monitor for early signs and symptoms -administer IV potassium only after adequate urine output has been established 13.4 Plan effective care of pts with the following imbalances: Potassium Excess (hyperkalemia) -monitor ECG, assess labs, monitor I&O, obtain apical pulse -limitation of dietary potassium and dietary teaching -administration of cation exchange resins (Kayexalate) -emergent care: IV calcium gluconate, IV sodium bicarbonate, IV regular insulin and hypertonic dextrose IV, beta-2 agonists, dialysis -administer IV slowly and with an infusion pump