Exam 2: NSG 3009/ NSG3009 (2026/2027 Update) Principles of Assessment | Comprehensive Questions & Answers | 100% Accurate Solutions | – South University

Exam 2: NSG 3009/ NSG3009 (2026/2027 Update) Principles of Assessment | Comprehensive Questions & Answers | 100% Accurate Solutions | – South University Q. How do you perform an eye exam? ANSWER -Pupillary light reflex exam: Shine penlight across pupil from the side and observe for direct and consensual pupillary constriction. Direct = constriction of illuminated pupil Consensual = constriction of other pupil not being illuminated -Diagnostics Positions Test: leads eyes through six cardinal fields to elicit muscle weakness (nystagmus) during movement. Normal response is parallel movement. Q. Consider developmental competencies related to ear exams. ANSWER (Infants) •The infant's eustachian tube is short and wide and positioned horizontally than the adult's eustachian tube. •This horizontal position makes it easier for pathogens to move from the nasopharynx to the middle ear and increases the possibility of ear infections. Q. Consider developmental competencies related to ear exams. ANSWER (Adults) •Otosclerosis is a common cause if conductive hearing loss in young adults between the ages of 20-40 years. •It is a gradual bone formation that causes the stapes to become fixed in the oval window which impedes the transmission of sound and causes progressive deafness. Q. Contusion (Bruise) ANSWER A mechanical injury (a blow) that results in hemorrhage into tissues. Q. Macules (Abnormal) ANSWER Small changes of color in the skin that are neither raised nor depressed Q. Papules (Abnormal) ANSWER A small, raised solid pimple or swelling, often forming part of a rash, typically inflamed, bur not producing pus. Q. Plaques (Abnormal) ANSWER Elevated, dry, thickened area with well-defined or ill-defined borders. Q. Wheal (Abnormal) ANSWER An area of skin that is temporarily raised, typically reddened and usually accompanied by itching. Q. Nodules (Abonormal) ANSWER Elevated lesions on the skin. They are larger than papules. Some are fixed to skin above or subcutaneous tissue below. Q. Vesicle (Abnormal) ANSWER A fluid-filled cavity or sac. Q. Bulla (Abnormal) ANSWER A bubble-like cavity filled with air or fluid. Q. Cyst (Abnormal) ANSWER A membranous sac or cavity containing a liquid or semi-solid substance. Q. What is ABCDE method for skin cancer teaching? ANSWER A: asymmetry: not regularly round or oval, two halves of lesion do not look the same B: border: notching, scalloping, ragged edges, poorly defined margins C: color: areas of brown, tan, black, blue, red, white, or combination D: diameter: greater than 6 mm E: evolving: refers to the "ugly duckling" sign, in which the suspicious lesion stands out as looking different Q. late clubbing ANSWER -Deformity of nails caused by a number of diseases mostly the heart and lungs -Caused by low O2 in blood proliferation of tissue under the nail plate causes angle to increase to 160 degrees Q. Early clubbing ANSWER the angle straightens out to 180 degrees, and the nail base feels spongy to palpation. Then the nail becomes convex as the digit grows Q. Diamond/ crystal gap test ANSWER test used to determine if clubbing of the nails has occurred. Q. Pressure Ulcers (Decubitus Ulcers) ANSWER Injury to the skin and underlying tissue resulting from prolonged pressure on the skin Q. Stage I pressure ulcer ANSWER Intact skin appears red but unbroken Q. Stage II pressure ulcer ANSWER Partial-thickness skin erosion with loss of epidermis or also the dermis. Superficial ulcer looks shallow like an abrasion or open blister. Q. Stage III pressure ulcer ANSWER -thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater. Q. Stage IV ANSWER Full-thickness ulcer involves all skin layers and extends into supporting tissue exposing bone, muscle, tendon, and may show slough (stringy matter attached to the wound bed). Q. Strabismus ANSWER (children & infants) (Abnormal) -Abnormal alignment of the eyes, squint. (crossed- eye) -Important screening in children ages 3-5. Q. Pseudo Strabismus ANSWER (children & infants) (Abnormal) -Epicanthal folds may give the false impression of malalignment, yet the corneal light reflex is normal Q. Cover-Uncover Test ANSWER The single cover test is a test is used to determine if there is a heterotropia or tropia, which is a manifest strabismus or misalignment that is always present. The first eye is covered for approximately 1-2 seconds. As this eye is covered, the uncovered eye is observed for any shift in fixation. Q. Pseudoptosis (Abnormal) ANSWER A false appearance of malalignment. Caused by hypertophia of eyelid skin. Q. Pinguecula (Abnormal) ANSWER Yellowish elevated nodules, which may occur with prolonged exposure to sun, wind, dust. Q. Arcus senilus (Abnormal) ANSWER Cloudy appearance of the cornea that occurs with age. It is caused by deposits of lipid material. Q. Xanthelasma (Abnormal) ANSWER Commonly occurring raised yellow plaques on the lids as a result of high and normal levels of cholesterol and have no pathological significance Q. Cataracts (Abnormal) ANSWER A clouding of the crystalline lens from a clumping of proteins. This is curable with lens replacement surgery. Age is the primary risk factor, about 17.2 % of Americans over 40 years of age have cataracts and by age 80, more than half of adults have cataracts. Q. Glaucoma (Abnormal) ANSWER A condition of increased pressure within the eyeball, causing gradual loss of vision Q. Macular Degeneration (Abnormal) ANSWER A degenerative condition affecting the central part of the retina (the macula) and resulting in distortion of or loss of central vision. It occurs especially in older adults. Q. Diabetic Retinopathy (Abnormal) ANSWER A diabetic complication that affects the eyes. It is caused by damage to the blood vessels of the light-sensitive tissue at the back of the eye. It is the most common cause of vision loss among people with diabetes and the leading cause of vision impairment in working-age adults. Q. Exophthalmos (Protruding eyes) (Abnormal) ANSWER associated with hyperthyroidism, Graves' disease. Q. Ptosis (Drooping upper lid) ANSWER (Children & Adults) (Abnormal) occurs with neuromuscular weakness (for example, myasthenia gravis) Q. Ectropion (Abnormal) ANSWER The lower lid is loose and rolling out. The eyes feel dry and itchy. It occurs in aging Q. Entropion (Abnormal) ANSWER The lower lid rolls in because of spasm of lids or scar tissue contracting. Blepharitis (Abnormal) Inflammation of the eyelid Chalazion (Abnormal) a swollen bump on the eyelid. It happens when the eyelid's oil gland clogs up. Eyelid may get red, swollen, and sometimes tender to touch Hordeolum (Stye) (Abnormal) mall, red, painful lump that grows from the base of your eyelash or under the eyelid. Most are caused by a bacterial infection. Dacrocystitis (Abnormal) Inflammation of the lacrimal sac Anisocoria (Abnormal) Unequal pupil sizes, affects 20% o the population. It may be harmless or indicate more serious medical problems. Mydriasis (Abnormal) Dilated or fixed pupils. Non-physiological causes may be disease, trauma, or the use of drugs. Miosis (Abnormal) constricted or fixed pupils. Possible causes include: bright lights, opiate intoxication, medication side effects, or aging. Conjunctivitis (Abnormal) Highly contagious infection of the conjunctiva. Commonly caused by viral, bacterial infection or allergy or chemical irritants. Iritis (Abnormal) Infection of the iris. Deep, dull red halo around the iris and cornea. The person has marked photophobia, constricted pupil, blurred vision, and throbbing pain. Primary Angle Closure Glaucoma (Abnormal) develops when the drainage in the eye is blocked because the iris has come forward, causing the drainage angle to 'close' and the eye pressure to rise. Circumcorneal redness around the iris, with a dilated pupil. Subconjunctival Hemorrhage (Abnormal) broken blood vessels in the eye. Looks alarming but is not serious. It occurs from increased intraocular pressure from coughing, vomiting or weight lifting. Corneal Abrasion (Abnormal) Corneal abrasion is the most common result of a blunt eye injury. Top layer of corneal epithelium is removed from scratches or poorly fitting or over-worn contact lenses. Papilledema (Abnormal) swelling of the head of the optic nerve, a sign of increased intracranial pressure. Hypertensive Retinopathy (Abnormal) is damage to the retina caused by high blood pressure. Over time, high blood pressure can cause damage to the retina's blood vessels, limit the retina's function, and put pressure on the optic nerve, causing vision problems. Arteriovenous Crossing "Nicking" (Abnormal) AV nicking. a vascular abnormality in the retina of the eye, visible on ophthalmological examination, in which a vein is compressed by an arteriovenous crossing. The vein appears "nicked" as a result of constriction or spasm. It is a sign of hypertension, arteriosclerosis, or other vascular conditions. Frostbite (Abnormal) is an injury caused by freezing of the skin and underlying tissues. First your skin becomes very cold and red, then numb, hard and pale. Frostbite is most common on the fingers, toes, nose, ears, cheeks and chin. Exposed skin in cold, windy weather is most vulnerable to frostbite. Otitis externa (Abnormal) is a condition that causes inflammation (redness and swelling) of the external ear canal, which is the tube between the outer ear and eardrum. Otitis externa is often referred to as "swimmer's ear" because repeated exposure to water can make the ear canal more vulnerable to inflammation. Drug of choice: Ciprofloxacin Sebaceous Cysts (Abnormal) are abnormalities in the body that may contain liquid or semiliquid material Tophi (Abnormal) A deposit of crystalline uric acid and other substances at the surface of joints or in skin or cartilage, typically as a feature of gout. Battle's sign (Abnormal) is a bruise that indicates a fracture at the bottom of the skull. Excessive Cerumen (Abnormal) Cerumen should be present. Used to lubricate, waterproof, and clean the external auditory canal. Also antibacterial and used to trap foreign bodies. -Cleaning Techniques: -No Qtips: can damage tympanic membrane or push wax further in ear -Can have ear canals irrigated and suctioned -Ear drops can be used to break up wax Abnormal Tympanic Membranes -Effusion = bulging membrane -Amoxicillin is drug of choice for children with otitis media. Perforated ear drum (Abnormal) occurs from increased pressure or trauma. Tympanostomy Tube A small tube inserted into the eardrum in order to keep the middle ear aerated for a prolonged period of time, and to prevent the accumulation of fluid in the middle ear. Epistaxis (Abnormal) Causes: -Traumatic: Digital Manipulation, Nasal Fracture/Contusion, Foreign body, Iatrogenic (NG insertion) -Tumors -Hematologic: hemophilia, thrombocytopenia -Structural: mucosal dryness, septal perforation -Drug-Related: anticoagulants, antiplatelets, steroid nasal sprays, nasal absorption of drugs -Inflammatory: allergic rhinitis, acute infectious diseases Rhinitis (Abnormal) inflammation of the nose Perforated septum (Abnormal) A hole in the septum, may be caused by snorting cocaine, chronic infection, trauma, or nasal surgery. Angular Cheilitis (Stomatitis) (Abnormal) Painful fissures at the corners of the mouth. Often seen in persons with poorly fitting dentures Carcinoma (Abnormal) a malignant tumor that occurs in epithelial tissue Risk Factors: -Prolonged sun exposure -Drinking -Smoking Herpes simplex labialis (Abnormal) Oral and/or topical acyclovir Baby bottle tooth decay (Abnormal) Occurs when sweetened liquids or those with natural sugars (like milk, formula, and fruit juice) cling to an infant's teeth for a long time. Bacteria in the mouth thrive on this sugar and make acids that attack the teeth. Gingivitis (Abnormal) Gum margins are red and swollen and bleed easily. Inflammation is usually caused by poor dental hygiene and Vitamin C deficiency. Aphthous ulcers ("canker sores") (Abnormal) Small, round, "punched out" ulcer. Cause is unknown but may be associated with stress, fatigue, and food allergy. Leukoplakia (Abnormal) Chalky, white, thick, raised lesions. It does not scrape off. It is caused by chronic irritation or heavy smoking and alcohol consumption. Candidiasis ("Thrush") (Abnormal) A white cheesy "curdlike" patch on the mucosa and tongue. It scrapes off, leaving a raw, red surface that bleeds. It occurs in newborns and as an opportunistic infection after the use of antibiotics and in immunosuppressed people. -Pharmacology: Treatable with Nystatin swish and swallow Black Hairy Tongue (Abnormal) Indicates a fungus infection on the tongue. It occurs after the use of antibiotics, which inhibit normal bacteria and allow proliferation of fungus, and with heavy smoking. CN 1 Olfactory (sensory) Function: sense of smell Test: smell test where patient is asked to identify odors. Testing one nostril at a time. CN 2 Optic (sensory) Function: Sight Test: visual acuity and visual fields of confrontation CN 3, 4, 6: Oculomotor, Trochlear, Abducens (motor) Function: eye movement Test: Check pupils for size, regularity, equality, direct and consensual light reactions and accommodation CN 5 Trigeminal (sensory & motor) Function: Face; sensory, motor Test: Test the muscles of mastication by palpating the temporal and masseter muscles as the person clenches his teeth; With the person's eyes closed, test light touch sensation CN 7 Facial (both) Function: Face; expression, sensory Test: Taste in the anterior two thirds of the tongue can be tested with sweet, sour, salty, and bitter solutions applied with a cotton swab first on one side of the tongue, then on the other CN 8 Vestibulocochlear (sensory) Function: hearing, balance Test: Test hearing ability. Rinne, Weber, Whisper tests. CN 9 Glossopharyngeal (both) CN 10 Vagus (both) Function: taste, gag reflex, parasympathetic innervation Test: Depress the tongue with a tongue blade and note pharyngeal movement as the person says "ash". CN 11 Spinal Accessory (motor) Function: Shoulder Shrug Test: Examine the sternomastoid and trapezius muscles for equal size and strength. Ask the person to rotate the head forcibly against resistance. CN 12 Hypoglossal (motor) Function: swallowing, speech Test: Inspect the tongue for wasting or tremors. Ask the person to say "light, tight, dynamite" Glasgow Coma Scale Mongolian Spots (Infants) (Normal) are a type of birthmark caused by the pigment in the skin; present at birth, but may also appear in the infant's first weeks of life. Café au Lait Spots (Infants) (Normal) flat, pigmented birthmarks; can be found anywhere. Cutis marmorata (Infants) (Normal) skin has a pinkish blue mottled or marbled appearance when subjected to cold temperatures. Rewarming usually restores the skin to its normal appearance Erythema toxicum neonatorum (Infants) (Normal) AKA newborn rash; benign condition thought to be caused by the activation of immune system Acrocyanosis (Infants) (Normal) blueness of the extremities caused by slow circulation Milia (Infants) (Normal) Distended sebaceous glands appear as tiny white spots on the baby's face. Stork Bite (Infants) (Normal) A patch of deep pink skin found at the nape of the neck Diaper Dermatitis (Infants) (Normal) Diaper rash is usually red, scaling and, rarely, ulcerated Intertrigo (children) (Normal) an inflammatory condition of skin folds, induced or aggravated by heat, moisture, maceration, friction, and lack of air circulation; frequently is worsened by infection, which most commonly is with Candida species Eczema (Children) (Normal) Noncontagious skin rash that produces itching, blistering, and scaling -can triggered by allergen exposure Measles/ rubeola (Children) (Normal) caused by measles virus Varicella (Infants) (Normal) chicken pox Acne (adolescent) (Normal) A skin condition that occurs when hair follicles plug with oil and dead skin cells Striae (pregnant women) (Normal) Reddened streaks that usually appear on the skin from rapid weight gain or from weight changes Linea Negra (Pregnant women) (Normal) "Pregnancy line "appears in about three quarters of pregnancies. chloasma (pregnant women) (Normal) Brown patches that appear on the face. Also called "the mask of pregnancy." Vascular spiders (Pregnant women) (Normal) It May occur when you have increased estrogen in the body system, during pregnancy. Senile lentigines (Older Adults) (Normal) Flat, tan, or black spots common with age. Keratoses (Older Adults) (Normal) A noncancerous skin condition that appears as a waxy, brown, black, or tan growth Actinic keratosis (Older Adults) (Normal) A rough, scaly patch on the skin caused by years of sun exposure. Xerosis (Older Adults) (Normal) Rough, dry skin that may have scales and small cracks. Sebaceous hyperplasia (Older Adults) (Normal) Common, benign condition of sebaceous glands in adults of middle or older age. Lesions can be singular or multiple found mainly on the face Abnormal skin color changes Pallor = pale = decreased amount of oxyhemoglobin... anemia Cyanosis = pail blue or gray = lack of oxygen circulation in the body Erythema = redness = limited area or all over Jaundice/Carotenemia = yellow Carotenemia (Abnormal) characterized by yellow pigmentation of the skin (xanthoderma) and increased beta-carotene levels in the blood. In most cases, the condition follows prolonged and excessive consumption of carotene-rich foods, such as carrots, squash, and sweet potatoes. Jaundice (Abnormal) a condition in which the skin, sclera (whites of the eyes) and mucous membranes turn yellow. This yellow color is caused by a high level of bilirubin, a yellow-orange bile pigment. Bile is fluid secreted by the liver. Bilirubin is formed from the breakdown of red blood cells basal cell carcinoma (Abnormal) malignant tumor of the basal cell layer of the epidermis squamous cell carcinoma (Abnormal) malignant tumor of the squamous epithelial cells in the epidermis malignant melanoma (Abnormal) Most serious form of skin cancer; often characterized by black or dark brown patches on the skin that may appear uneven in texture, jagged, or raised. Lichenification (Abnormal) Prolonged scratching that thickens the skins and produces tightly packed sets of papules Keloid (Abnormal) overgrowth of scar tissue Telangiectasia Caused by vascular dilation, permanently enlarged and dilated blood vessels that are visible on the skin surface Spider or Star Angioma (similar to vascular spiders) A fiery red star-shaped marking with a solid circular center; capillary radiations extend from the center Venous Lake (Abnormal) A blue-purple dilation of venules and capillaries in a flaring pattern. Pressure causes them to empty or disappear Ecchymosis (Abnormal) A purplish patch resulting from extravasation of blood into the skin Purpura (Abnormal) Confluent and extensive patch of petechiae and ecchymoses 3 mm, flat, red, purple identify patient at risk, recognize SSx of imbalances, intervene with appropriate interventions, evaluate response As a nurse caring for a patient, what is your role in regards to fluid and electrolytes? 40% The intracellular compartment makes up __% of fluid composition. 4% The intravascular compartment makes up __% of fluid composition. 16% The interstitial compartment makes up __% of fluid composition. 30 ml/hr; to make sure kidneys are working What is the normal amount of urine output and why do we need to monitor it? weight-best indicator of fluid loss/gain How do you know if Lasix is working? too much If your patient gains 2-3 lbs overnight, is that too much, too little, or normal? Too much If your patient gains over 5 lbs in a week, is that too much, too little, or normal? thirst (sodium), ADH, kidney (GFR), RAAS, ANP, capillary exchange, aging What affects fluid regulation? blood pressure and fluid What is hydrostatic pressure? glucose Plasma colloid osmotic pressure=? proteins oncotic pressure=? crackles in lungs How do you know when someone is getting too much fluid thru IV? fever, vomiting, diarrhea, heat exhaustion, blood loss, overuse of diuretics, third spacing, decrease intake, diabetes insipidus (not enough ADH), hyperventilation, poor intake of fluids, CHF, exercise What are some ways someone can become dehydrated/hypovolemic/experience fluid loss? dry skin, poor skin turgor, elevated temp, tachycardia, dry mucous membranes, decreased urine output (amber colored), postural hypotension, weight loss, increased Hct/BUN/albumin/serum creatinine levels, acute renal failure What are some SSx of dehydration? know how to test for it (lying, sit, stand- 20mmHg difference for systolic/10 fir diastolic) Postural hypotension accumulation of urea & other nitrogen containing substances in blood stream What is acute kidney injury? V/N, headache, increase in potassium, increased BP, fatigue, loss of appetite What can acute kidney injury lead to? closely monitoring fluid balance, I/O How can we prevent dehydration in elderly pts? surgery, NPO, NG, poor appetite, elderly, diuretic, diabetic (elevated blood glucose) What are some risk factors that can lead to your patient becoming dehydrated? notify MD, offer oral fluids, start IV, administer IV fluids per MD order, monitor I/O You notice that one of your patients is showing signs of dehydration. What are some nursing interventions you should do? dehydration (because diabetes insipidus has decreased ADH) People with brain trauma/surgery are at risk for diabetes insipidus. What does this also put them at risk for? begin with small amt of oral re-hydrating solution (ORS mild-best way to get fluid back in the mouth), IV fluid replacement (isotonic, hypotonic, hypertonic), IV bolus What are some treatments for dehydration? monitor respiratory effort, auscultate lungs for crackles, O2 Sat Your patient is on a care plan to get rehydrated. In the process, you have to monitor for fluid overload. How/what do you monitor for? give Lasix (with Dr order) Your patient has heart failure. What med would you give? normal distribution The first space has what kind of water distribution? fluid in interstitium (edema) The second space has what kind of water distribution? fluid in other compartments (ascites, edema from burns, damage to capillary wall The third space has what kind of water distribution? Examples? moist mouth, urine output/color, better BP, skin turgor improves How do you know when someone is getting hydrated? drainage of fluid out of the abd What is a paracentesis? edema in lower extremities If there isn't enough protein in the bloodstream, what can happen? excess fluid in interstitial compartment; increased hydrostatic pressure, sodium, heart failure, decreased plasma oncotic pressure, low protein, increased capillary permeability What is edema and what are some things associated with it? excess fluid intake/fluid retention, SIADH, excessive intake, psych disorder (water intoxication) What is hypervolemia and how can it happen? acute (confusion and convulsions) chronic (weakness, N, muscle spasm) dilutional hyponatremia What are some SSx of hypervolemia? restrict fluids, diuretics, SIADH (hormonal replacement), restrict sodium What are some treatments for hypervolemia? potassium What electrolyte should you watch with salt substitutes? sodium this electrolyte affects CNS function and transmission of nerve impulses euvolemic hyponatremia sodium is low with normal fluid volume hypovolemic hyponatremia need more fluid and salt hypervolemic hyponatremia get rid of fluid and salt decreased sodium loss and decreased H2O What is hypovolemic hyponatremia? hypo: irritable, confused, postural hypotension, dry mucus membranes, N, weight loss hyper: lethargy, headache, weakness, confusion, weight gain, elevated BP, muscle spasms/seizures, peripheral edema What is the difference between hypo and hypervolemic hyponatremia? excess H2O gain-dilutional SIADH What is hypervolemic hyponatremia? severe-hypertonic solution- 3% saline at rate of approx. 1-2mL/kg/hr loop diuretics- used with NS or 3% saline to prevent volume overload and potentiation of CHF How do you treat hypovolemic hyponatremia? restrict fluids, diuretics, treat cause How do you treat hypervolemic hyponatremia? yep Does 3% saline have a lot of salt in it? potassium major ion, 98% intracellular, small changes= profound effects of CV system & NM system, excess excreted by kidneys potassium deficit (3.5mEq/L); vomiting, prolonged GI suctioning, drugs (insulin pushed K into the cell, diuretics, digoxin, thiazides), inadequate intake, excessive output What is hypokalemia and what are some causes? weakness, leg cramps, constipation, EKG changes What are some SSx of hypokalemia? bananas, OJ, chocolate, potatoes, tomatoes, oral K supplement, IV potassium supplement (slowly or V-fib to cardiac arrest-always check K level before giving) What are some ways to treat hypokalemia? never IV push, no more than 40-60 mEq/dose, use infusion device, monitor site for phlebitis and necrosis, monitor urine output (30cc/hr), monitor heart rhythm What are some things to remember with IV potassium? hyperkalemia potassium level 5.5 mEq/L, more serious than hypokalemia, Addison's disease, massive blood transfusions, addition of potassium into extracellular space, cell injury (burns/phlebotomy/chemo), chronic renal failure slow down and call Dr Your patient is getting potassium IV and just told you that their arm (with the IV site) burns. What do you do? breakdown of muscle (drugs) What is rhabdomyolysis? spironolactone, ACE inhibitors, antibiotics, NSAIDS What are some drugs related to hyperkalemia? neuro changes (weakness, fatigue, ascending paralysis), respiratory failure, CV symptoms (palpitations, dizziness secondary to arrhythmia, sudden cardiac arrest, hypotension, irregular pulse, bradycardia, ECG changes, abd cramping, D What are some SSx of hyperkalemia? initial- T waves peaked/tented next- ST depression, first degree AV block, QRS widening final- imminent ventricular standstill, complete heart block, elextromechanical dissociation What does hyperkalemia look like on EKG? glucose & insulin infusion, Lasix, dialysis What are some treatment/drug therapies for hyperkalemia? regular 10 units IV, glucoe 50% (25 grams) 1 ampule IV over 5 min, onset 50-60 min, duration: several hours Describe the glucose and insulin infusion treatment for hyperkalemia? 40-80 mg Lasix IV to all patients who can produce urine Describe the Lasix treatment for hyperkalemic patients? dialysis this treatment is the primary therapy when renal function is absent, prompt-pts with ARD + associated rhabdomyolysis (large potassium load), for intractable hyperkalemia unresponsive to meds Hypomagnesemia 1.5mEq/L (magnesium) chronic alcoholism, leafy greens, meats, nuts, whole grains, dry beans/peas What are some causes of hypomagnesemia? irritation of CNS (confusion, insomnia, vertigo, tremors, twitching), suspect hypocalcemia also and check Chvostek's (facial twitching when the facial nerve is tapped) & Trousseau's (carpal spasm when upper arm is compressed) What are some SSx of hypomagnesemia? correct underlying cause, po or IV MgSO4; IV given slowly over 1 hr (too fast=cardiac arrest) How can you treat hypomagnesemia? Hypermagnesemia 2.5mEq/L (magnesium) too much intake, renal disease What are some causes of hypermagnesemia? lethargy, weakness, N/V, flushing, hypotension, bradycardia, cardiac/respiratory arrest What are some SSx of hypermagnesemia? increase fluids, diuretics, Ca+ salts to oppose effects of mg+ on cardiac muscle What are some treatments for hypermagnesemia? 2.5mg/dl hypophosphatemia 4.5mg/dl hyperphosphatemia osteoblast What type of bone cell is responsible for the formation of bone? protect & support organs, production of WBC/RBC, mineral storage What are the functions of the MS system? bones composed of three materials (collagen, calcium, phosphate) osteoblast bone builders/forming cells osteocytes mature bone cells osteoclasts collapses, breakdown, or remodels bone (resorption) osteoblast, osteocytes, osteoclasts What are the 3 types of bone cells? true; stores phosphorus and calcium T/F: medullar cavity contains the red or yellow bone marrow. immovable what is a synarthrotic joint? slightly movable what is an amphiarthrotic joint? freely movable what is a diarthrodial joint? move in relation to each other What is the articulation joint? free moving, lubricated What is a synovial joint? cartilage this is located in synovial joints, has three types (hyaline, elastic, fibrous) cardiac, smooth, skeletal What are the three types of muscle? attach muscle to bone What is the function of tendons? connect bone to bone What is the function of ligaments? past health Hx, meds, surgery/other Tx, health perception, physical exam What is some subjective data you can obtain when assessing for MS deviations? immobilize the leg before moving he client- more important than checking pedal pulses because immobilizing the leg could affect pulses & if she moves more it can cause more damage A nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the priority? pain pallor(temp) pulse loss parasthesis (tingling/needles) paralysis pressure perfusion (cap refill) What are the 7 P's to asses for in MS system? x-rays, MRI, bone scans, diskogram, CT scan, myelogram with/without CT, MRI, BMD, ANA, anti-DNA antibody, CH50, uric acid, CRP, HLA-B27, alkaline phosphatase, serum calcium, serum phosphorus, rheumatoid factor (RF), ESR, creatine kinase, serum K, aldolase, EMG What are some diagnostic studies of the MS system? standard x-ray What is the most common diagnostic test used to asses MS disorders? bone scans this diagnostic tool is used to look at bone density- a lot of women & bone deformities) inject an isotope; might have to hold Metformin as we get older When would we get a bone mineral density test (BMD)? renal disease serum calcium tests for Ca malabsorption serum phosphorus tests for swan neck Rheumatoid factor can be characterized by cancer too much reabsorption can indicate presence of antibodies that can destroy nucleus (Lupus, RA) the ANA (antinuclear antibody) diagnostic study tests monitor for swelling, bleeding, hematoma formation What is nursing care after a bone biopsy? mother does the mother or the father carry muscular dystrophy? autoimmune diseases, rheumatoid, osteoporosis, MD, osteoarthritis, gout, scoliosis What are some MS disorders that carry a genetic risk? decreased activity of daily living, chronic pain, immobility, increased risk of falls/changes in balance, loss of strength, altered proprioception (awareness of self/environment), altered bone remodeling process, decreased muscle mass and strength, loss of motor neurons, less flexible tendons/ligaments, movements become more rigid, arthritis What are some elderly considerations with the MS system? do passive ROM; poor bone density= risk for falls Your elderly patient has osteoporosis and rigid movements. What are some considerations when assessing your patient? have pt exercise to maintain muscle strength and avoid risk for falls A 78 y.o. woman has physiologic changes related to aging in her joints. What is an appropriate nursing intervention related to common changes of aging in the MS system? sprains, strains, dislocation, subluxation, carpal tunnel syndrome, rotator cuff injury, meniscus injury, bursitis What are some soft tissue injuries? contusion soft tissue injury caused by blunt force strain pulled muscle, injury to a musculotendinous unit caused by overuse, overstretching or excessive stress sprain twisting injury to the ligaments and supporting muscle fibers surrounding a joint rest, ice, compress, elevate (RICE) A pt with a sprain should be told to do what before going home? dislocation severe complete displacement or separation of the articular surface (less severe) pedaling pedals a cast like a flower to keep cast from rubbing skin splint used for conditions that do not require rigid immobilization, or when edema is anticipated, or for those who require special skin care braces for long term use to provide support, control movement and prevent accidental injury stomach, heart, kidneys (for inflammation) When your pt is on NSAIDS what should you watch for? decreases local inflammation and pain What does RICE do for managing soft tissue? INTERMITTENTLY For some injuries, after initial inflammatory phase 24-48 hr, heat may applied how? stopping the activity and limiting movement, applying ice compression to injured area (immediately after/ not to exceed 20-30 min per application, not directly on skin), compressing the involved extremity, elevating the extremity 24-48 hrs after injury, provide analgesia For emergency management of soft tissue, what is the nurse's acute intervention focus? cryotherapy ice-cold therapy, polar care, vasoconstriction, decreases nerve transmission=decreases pain, reduces inflammation, 20-30 min on/20-30 min off cryotherapy What kind of therapy is used for total knee replacements? wrap outward toward the heart= increases circulation How do you wrap an ACE bandage? compartment syndrome this is very serious; NEVER elevate the legs; surgery is the only thing to fix it carpal tunnel syndrome compression of the median nerve that enters the hand by way of the narrow spaces of CT; musician, painter, sewer, diabetics/hypothyroidism at high risk (any repetitive motion) tested with tinel's sign and Phalen's maneuver tingling over the medial nerve with light percussion What is tinel's sign for carpal tunnel testing? position for 60 sec to check for tingling/numbness What is Phalen's maneuver for carpal tunnel testing? carpal tunnel release (surgery) or splints (can't move hand for 4 weeks in a brace after surgery) cortisone How can carpal tunnel be treated? rotator cuff tear injury to one of the tendons in the shoulder joint meniscal injuries A lot of sports related knee injuries are: RICE, evaluate for fracture, immobilize/brace/crutches, PT, NSAIDS/analgesics, arthroscopic reconstructive surgery, Weight bearing as tolerated, treatment in outpatient setting What are ways we can manage knee injuries? immobilize it and control pain What are the two goals for managing knee injuries? monitor neurovascular status, cryotherapy, leg exercises/ROM/PT, knee brace/immobilizer, weight bearing may be restricted prn, NSAIDS/analgesics As a nurse, how are you to provide post-op care for arthroscopies? no- proper fit is important. never try to fit a brace if you have not been properly trained! You are the only available nurse on the floor of 8 patients because of an emergency in the ED. The doctor leaves a patient in their room with a brace sitting next to the bed. As you go around to each patient, doing what nurses do and whatnot, your patient (very irritated) asks you to put the brace on him. Is that something that you can do? dehydration NSAIDS can lead to __ in elderly person if they aren't drinking enough. bursitis inflammatory condition of the bursa; inflammation of the fluid filled sac (bursa) that lies between a tendon and skin or btwn tendon and bone; the condition may be acute or chronic bursitis at the elbow What is olecranon bursitis? fractures break in the continuity of bone and is defined according to the type and extent; occurs when bone is subjected to stress greater than it can absorb realign as best/much as we can; anatomic realignment, immobilization to maintain alignment, restoration of normal or near to normal function achieved by: fracture reduction, fracture immobilization, drug therapy, nutritional therapy What is the goal in collaborative care when nursing a fracture? How do we achieve this? nonsurgical closed reduction of a fracture is: got to have surgery/pins When a fracture has open reduction what has to happen? leads to less problems with muscle spasms Out of all the ways we can reduce a fracture (closed reduction, open reduction, and traction), what about traction is different? infection Besides pain, what is the number one priority when nursing for a patient with a fracture reduction? casting a rigid external immobilizing device that is molded to the contour of the body in order to immobilize a reduced fracture, correct deformity, apply uniform pressure to soft tissues, stabilize weak joint, follow closed reduction, and non weight bearing for 24-72 hours minimize skin irritation The edges of the cast can be petaled with tape for what reason? don't stick anything down there-even if it itches What is one thing to teach your patient about their new cast/how to take care of it? acute pain, deficient knowledge, impaired physical mobility, self-care deficit, impaired skin integrity, risk for peripheral neurovascular dysfunction, cast care What are some things to manage when our patient has a cast? it's still wet Why can't we touch a cast when it's first been done? hot spot on the cast A nurse is checking the casted extremity of a client. The nurse would check for what SSx indictive of infection? corticosteroid injections, opioids, NSAIDS, local analgesics (lidocaine), tetanus & diphtheria toxoid immunization, antibiotics (Ancef, cephalosporin-bone penetrating) What are some meds for injuries/surgeries of the MS system? pt has severe asthma and requires frequent therapy with steroids When the nurse is assessing a new patient in the clinic, which info about the pts medications will be of most concern? loss of height The nursing is caring for a 74 y.o. woman. What would be a normal age-related finding? report headache that is worse when sitting or standing The nurse is providing discharge teaching to a pt who has a myelogram. What would the nurse include in the teaching plan? measure the length of both legs the nurse notices that a pt has disturbed gait. to further assess this problem, what action should the nurse take? harmful to liver max dose/day= 4,000 mg (4g) What are some major things to remember about Tylenol? dehydration can cause acute renal failure; can interfere with platelet aggregation especially if taking aspirin or other blood thinners What are some major things to remember about NSAIDS? protein, Vitamin B/C/D, calcium, phosphorus, magnesium What minerals/vitamins are important for good nutrition to promote strength, energy, and healing? constipation narcotics cause __ 2,000-3,000 ml/day How much fluid should we intake per day? the pt is 5ft 2in tall and weighs 180lbs which info obtained during the nurse's assessment of the pts nutritional-metabolic pattern may indicate the risk for MS problems? intracapsular and extracapsular what are the types of hip fractures? intracapsular (your eye ("I"ntracapsular) is closest to your NECK this hip fracture is a fracture of the neck of the femur extracellular fracture of the trochanteric region (type of hip fracture) administering the ordered oral opioid pain med when preparing a pt to ambulate the day after an ORIF for a hip fracture, what action is most important for the nurse to take? joint surgeries most common orthopedic operation for older adults relieve chronic pain, improve motion, correct deformity/mal-alignment, arthritis, CT disorders, hip dysplasia (congenital), Paget's/spondyloartaropathies Joint surgeries are performed to do what? (What's their purpose) you have an appointment with a PT for tomorrow a 20 y.o. baseball pitcher has an arthroscopic repair of a rotator cuff injury. post-op instructions include what info? joint surgeries synovectomy, osteotomy, debridement, arthroplasty are all __ __. synovectomy joint surgery where the synovial membrane is removed to treat RA osteotomy joint surgery where a slice/piece of bone is removed to change alignment to shift weight bearing debridement joint surgery where the degenerative debris are removed, ex. loose bodies, degenerative menisci arthroplasty joint surgery where a joint is reconstructed or replaced to relieve pain, improve ROM, correct deformity osteomyelitis infection of the bone; causes necrosis and breakdown of bone sudden pain, heat, red, swollen, black tissue, restricted What are some SSx of osteomyelitis? rest, decrease motion, give antibiotics (after culture of course) What are some treatments for osteomyelitis? when you need immediate help bc you cant do it by yourself (400lb man fell on the floor) When would you call rapid response? pt crashing/CPR needed When would you call code blue? herniated disks What is the number one problem of low back pain? rest, brace, limit spinal mvmt, drug therapy, muscle relaxers What are some conservative treatments for herniation? clean them (the pins)!!! What is a MAJOR priority when your patient has pins sticking out of the leg from surgery? laminectomy surgery for herniated disk; excision of posterior part of vertebra (lamina) to remove herniated disk material diskectomy surgery for herniated disk; microsurgical spinal fusion surgery for herniated disk; used with unstable bony mechanisms; bone grafts taken from iliac crest may involve cadaver bone- rods, plates, and screws may be used WATCH FOR RISK OF BLEEDING not to sit or stand for prolonged periods When logrolling a pt, what should you instruct them to do? CSF leak (look at incision site-halo sign or glucose check if clear; should be clear=nothing in it) and new muscle weakness (from spinal cord compression) &/or paresthesias what is your main focus post op of spinal surgery in particular? pre-op baseline assessments are a must, sensation, movement, muscle strength, wound, pain How/what should you observe & document post-op of a spinal surgery in particular? poor posture, traumatic injury neck pain can be due to: stiffness, neck pain, radiating into arm/hand/head/anterior chest, thoracic spine pain, shoulder pain, if compressed nerve-weakness, paresthesia from arm/hand What are some SSx of neck pain? history & physical, x-ray, MRI, CT scan, myelogram How can neck pain be diagnosed? use of supportive cervical collars, heat and ice application, massage, rest, PT, acupuncture, NSAID, surgical intervention last What are some ways to treat neck pain? avoid prolonged sitting at computer/TV, avoid sleeping in non-alignment spinal positions, avoid jarring mvmts during exercise, important to practice good posture and maintain neck flexibility, patient and caregiver teaching guide You client wants to know how he can prevent neck pain. What are some things you can educate him with? congenital, structural weakness, trauma, systemic (DM/RA), improperly fitted shoes Foot disorders can be due to: proper foot wear (especially older adults- no heels 1in tall) What is one thing you can teach your client, related to foot disorders and preventing them? plantar fasciatis a foot disorder where the pain can be treated with a frozen water bottle covered by a towel or a tennis ball rolling under the affect foot referral to podiatrist, NSAIDS/corticosteroid shots, shock wave therapy, icing, stretching, warm soaks, orthotics, alteration in foot wear, surgery (last option)- placing pins or wires thru toes/bunion removal) What are some acute interventions for foot disorders? immobilize with bulky dressing, short-leg cast, slipper (plaster) cast, elevate heel off bed to decrease edema/with frequent rest periods, asses neurovascular status (gait, pain), PT, crutches, walker, cane, normal feeling throbbing sensation when first starting ambulation What is some post-op care after a surgery to treat a foot disorder? rickets osteomalacia; not enough vitamin D labs, x-rays correction of vit. d deficiency, use of vit. d supplements, calcium salts or phosphorus supplements, plenty of exposure to sunlight (weight bearing exercise) What are some ways to diagnose osteomalacia? How should we do collaborative care for pt with this? elevated alkaline phosphate, phosphorus level, calcium level What are three labs you'll see elevated with osteomalacia? increase eggs, meat, oily fish, cereals with Calcium/vit. d, milk What are some dietary changes a pt with osteomalacia can make? diet low in calcium, sedentary lifestyle, cigarette smoking people who smoke/drink alcohol are at high risk, heparin/Dilantin too; women need to do weight bearing exercises What are some risk factors for osteoporosis? decreases does heparin/Dilantin decrease or increase calcium absorption? cancer Why is estrogen taken away at a certain age? protects the bones Evista works like estrogen and: paget's disease excessive bone resorption followed by replacement of normal marrow by vascular fibrous CT; new bone larger and disorganized and weaker, genetic waddling gait, most common for acute dementia What is a major sign of paget's disease? Who is it most common for? Alkaline phosphatase What lab/diagnostic should you run for paget's disease? treat symptoms, surgical intervention, braces, administer human calcitonin (decreases serum A/P, inhibits osteoclastic activity, vit. d/Ca supplements, NSAIDS, orthopedic surgery for fractures, hip/knee replacement surgery, knee realignment) How should collaborative care be done for a pt with paget's disease? AM OA is mostly stiff in the (AM/PM?) but gets better. RA (rheumatoid arthritis) usually affects joints symmetrically, may initially begin in a couple joints only, most frequently attacks the wrists/hands/elbows/shoulders/knees/ankles NSAIDS, steroids (prednisone/methylprednisolone), disease-modifying anti-rheumatic drugs (look at slide for that or book cuz I don't feel like writing them things out), immunosuppressants (azathioprine (Imuran, Azasan)-going to inhibit immune system), TNF alpha inhibitors (look at slide/book) How can you treat RA? (hint- almost all MS problems are treated the same) spondyloarthropathies a group of interrelated multisystem inflammatory disorders that affect the spine, peripheral joints, and periarticular structures; includes ankylosing spondylitis, psoriatic arthritis, reactive arthritis gout when you hear this think PAIN, with this-stop eating red meat primary gout this type of gout has an increase in uric acid secondary gout this type of gout has higher uric acid levels than the other type of gout; from diuretics, immunosuppressants, thiazides, chemo high saturated fats, meats, fried food What food should you avoid with gout? antigout drug (Zyloprim, allopurinol blocks uric acid production and colchichine blocks inflammation caused by uric acid crystals), corticosteroids, decrease purine intake (read meats, organ meats), may see Na bicarbonate given to alkalinize urine, rest-pain meds-encourage fluids (2 L/day) What are some interventions/Tx for gout? fibromyalgia widespread pain in the muscles and soft tissues above and below the waist and on both sides of the body; a syndrome- set of Sx that happen together but don't have a known cause the nervous system isn't able to control what is feels so ordinary feelings from muscles/joints/soft tissues are experienced as pain; people with this feel pain/tenderness even when there is no injury/inflammation What happens to the nervous system with fibromyalgia? steroids, exercise therapy, cognitive-behavioral therapy, SSRI's, tricyclic antidepressants, muscle relaxants, anticonvulsants how is fibromyalgia treated? no lab tests, Hx with Sx, widespread pain in all four quadrants of body for minimum duration of three months, tenderness/pain in atleast 11 of the 18 specified tender points when pressure is applied How is fibromyalgia diagnosed? chronic fatigue syndrome debilitating fatigue, immune abnormalities, women more affected than men, poorly understood condition, etiology unknown develops insidiously (slowly), intermittent episodes that gradually become chronic, incapacitating fatigue, triggering event (flu like illness or acute stress), effects work/family/ADLs What are some clinical manifestations of chronic fatigue syndrome? NSAIDs used to treat HA/muscle joint pain, antihistamines, decongestants, tricyclic antidepressants, well balanced diet (fiber and fresh dark colored fruits/veggies for antioxidant action), behavioral therapy How is chronic fatigue syndrome treated? yogurt, green veggies, dairy products What foods are high in Calcium? surgery art and science of treating diseases, injuries, and deformities by operation and instrument for the purposes of diagnosis, cure, palliation, cosmetic improvement, prevention, exploration excision/removal (hysterectomy) -ectomy destruction (lysis of incision) -lysis repair/suture (herniaorrhaphy) -orrhaphy scope/looking into (laproscopy) -oscopy opening (colostomy) -ostomy cutting into/incision of (laparotomy) -otomy repairing (rhinoplasty) -plasty only by pt and somebody doing surgery (surgeon); consent is only good for what pt agrees to & up to date; nurses can only WITNESS consent Who can sign consent forms? preop takes care of consent forms, no jewelry/teeth, start IV, checklist, get pt. ready, knows meds, pregnancy test, ptt/Pt/INR morning of surgery intraop actual surgery procedure, who/what is being done/is needed, role of different nurses, delegation, OR post op CRNA/RN hand off communication, assess for problems (pain, N, airway, etc.) normal saline and lactated ringers What are the two most common fluids for replacement and maintenance? the pt (youre emancipated when you got a kid) 17 y.o. female getting surgery. she has a two year old daughter. the pt's mother wont let her sign consent because she is not 18. who signs the consent form? on admission advance directives (durable power of attorney and living will) is done when? physical condition, previous experience, mental attitude, expected outcomes, understanding of surgical procedure (informed consent), cultural and religious beliefs, meds (allergies!), smoking/alcohol, coping resources, complete head-to-toe, NPO, gerontologic considerations What is a preoperative nurse supposed to cover in their history and assessment with the pt.? minors (18 y.o. unless emancipated) unconscious or injured in a way that they are unable to give consent mentally ill individuals who have been judged incompetent What are the three groups that cannot give consent? (sign the consent form) agreement by pt to accept a course of treatment after complete info, including risks of the treatment and facts relating to it; responsibility of physician; nurse's responsibility is to witness the giving of informed consent What is informed consent and who has the responsibility of it? ask additional questions to verify allergy (what happens when you come in contact to latex) The pt tells you that she has noticed she ahs a reaction when wearing gloves. what is the most appropriate intervention by the nurse? cardiac conditions, blood coagulation disorders, upper respiratory tract infections/COPD, renal disease, DM, liver disease, uncontrolled neurological disease What are some health problems that can increase surgical risk? UA, CBC, chest x-ray, EKG, blood grouping and cross matching, fasting blood sugar, BUN/creatinine (not going to give insulin unless it's way out of whack- anesthesiologist is responsible for that What are some routine preop screening/tests? proper ID using name and birthday or MR number, correct site/side, agreement on procedure, correct client position, availability of any special equipment or implants for procedure What are some safety precautions pre/intra op? mark before sedating pt, mark with marker near incision site, use "yes" indicating proposed area for surgery, entire team does final verification, must be visible after prepping and draping How are we supposed to use safety precautions in pre op (specifically for having the correct side/site)? surgeon-not nurse; has to write "yes" with initials on correct surgical site Who is responsible for marking the correct side/site before a surgery? look up clear diet in book look up liquid diet in book leg exercises these cause pressure to go up and down to keep circulation going atelectasis can lead to pneumonia, trouble breathing, look at chest symmetry, listen to sung sounds; use incentive spirometer they need to sit up and inhale and hole, breath for 5 sec atleast 10 times/hr while awake, 1500=1st goal, 2500=2ng goal How should your pt use their incentive spirometer? drains have to empty these and chart I/O every shift (even as a student) void before pre-op preg check on chart Along with other things on the preop checklist, what are two more things to really remember? (look at checklist in slides) ask why she has concern (thennnnn tell surgeon) Lady says she wont make it thru surgery. what do you say? history and assessment verify procedure mark site for surgery give preop versed and sublimize What is the correct pre-op priority order? get surgeon to asnwer his questions (call and tell them they have questions) Pt wants more info on procedure. how should you handle it? 5.5-6.0 What is a mild condition of hyperkalemia? 6.1-7.0 What is a moderate condition of hyperkalemia? 7.0 and above What is a severe condition of hyperkalemia? circulating nurse this intraop nurse in nonsterile; assists with prep of OR room; monitors activities of others; identifies/assesses pt; checks chart for pertinent info; admits pt to OR suite; positions pt and placing grounding pad on pt; documents intraop care; records/labels specimens; measures blood/fluid loss; counts surgical tools (sponges, etc.); accompanies pt to PACU; reports info to RR nurse- hand off communication hyperkalemia= high/peaked big time T-wave hypokalemia= flat T-wave What is the difference in the T-waves on an EKG of a pt with hyperkalemia and hypokalemia? sterile; assist with prep of room; scrubs/gowns/gloves self & other team members; prepares instrument table; assists with draping; passes instruments to surgeon; counts surgical crap (sponges, etc.); monitors aseptic technique of others and self; keeps track of irrigation solution used (in order to get accurate blood loss); reports amt of local anesthesia used what is the role of the scrub nurse? all boney prominences must be padded (elbows, heels, head), pt should have safety strap at waist and legs; arms should be strapped to arm boards or tucked with sheet alongside body How should you position the patient in OR? pt ID/allergies, surgical procedure, correct site/side, x-rays, implants It is universal protocol that the entire OR staff in the OR room checks: alcohol, chlorohexidine, iodine/idophors, triclosan What are some agents that are antimicrobial agents with a broad germicidal range and is nontoxic that we use for preop skin prep? general, regional, local, conscious sedation (Twilight sleep) What kinds of anesthesia are there? general anesthesia this type of anesthesia has loss of sensation with loss of consciousness; IV induction; barbiturates (Pentothal); nonbarbiturates (Diprivan); inhalation agents (volatile liquids/gasses) halothane, ethrane, forane, suprane, ultane What are some volatile liquids used for general anesthesia? narcotics (morphine, fentanyl); neuromuscular blocking agents (anectine, tracrium, mivacron, curare, pavulon); antiemetics (inapsine, Zofran, reglan, Phenergan) What are some adjuncts to general anesthesia? succinylocholine (Anectine) What adjunct to general anathesia can trigger malignant hypothermia? CO2, muscle rigidity, tachycardia, temp goes up, use dantrium (Dantrolene) What are some Sx and Tx for malignant hypothermia? regional anesthesia this type of anesthesia is a loss of sensation to a region of the body when a specific nerve or group of nerves is blocked with admin of local anesthesia without loss of consciousness; spinal, epidural, peripheral nerve block local anesthesia this type of anesthesia is loss of sensation without loss of consciousness; induced topically or via infiltration intracutaneously or subcutaneously; lidocaine and Marcaine; agents may be used with out without epinephrine conscious sedation (twilight sleep) this type of anesthesia is a depressed LOC following IV admin of benzo, usually in combination with a narcotic; pt retains the ability to maintain airway and respond to verbal commands; can't do as RN- have to have extra training (even a surgeon can't do it) anesthesiologist/CRNA and circulator must transfer pt to PACU; report given to PACU nurse- hand off communication Describe who is involved in transporting a pt to the PACU after surgery. postop care phase what care phase begins with admission to the PACU immediately after surgery until the pt gets DC includes assessment and monitoring of respiratory function, circulatory function, pain, temp, surgical site, maintaining proper function of bedside equipment What are some nursing considerations in the PACU? Demoral this drug can stop post-op shivering (when shivering isn't related to temp) general pt info (identify confirmed, arrival time documented, surgeon and surgical procedure) & pt history (med history, allergies, LOC) What should take place in the admission report to PACU? titrate drips, meds administered, estimated blood loss, total fluids given (including blood), urine/NGT output, drain output What are some things included in an intraop pt history? unexpected surgical/anesthesia event/reactions, VS, monitoring trends, lab results, complications (difficult intubations, etc.), review Dr order together what is included in the intraop course? hearing what is the first sense to return in the unconscious pt? ABC (airway, breathing/respirations, circulation), VS, LOC/PERLA, recovery from anesthesia, surgical site status, IV lines/infusion rates What is included in the assessment of the PACU pt? remember ABC's; most arrests due to airway obstruction, apnea, weak respirations, hemodynamic instability, safety risk due to altered mental status What are some nursing considerations for a PACU pt coming out of anesthesia? assess airway patency and breath sounds, jaw thrust/chin lift, O2, stimulation, oral airway, when conscious-elevate HOB What are some nursing managements of airway problems? airway obstruction tongue falls back and obstructs the posterior part of the pharynx; snoring, nasal flaring, sternal retractions, sleep apnea, hypoxemia (SaO2 90-92%, PaO2 60%) eliminates anesthetic gases, increased demand for O2 due to decreased blood volume, increased cellular metabolism; Why do we put O2 on our PACU pts? laryngospasm less common, partial or complete spasm of the vocal cords, Hx of smoking, difficult intubations, or history of vocal cord surgery; agitation, hypoxia, partial obstruction, complete obstruction gentle suctioning, maintain optimal airway position, 100% O2, + pressure ventilation (bagging), possible reintubation may be necessary but is not desirable How do we manage laryngospasms? atelectasis (alveolar collapse) The most common cause of postop hypoxemia is: pulmonary edema abnormal accumulation of fluid in alveoli and interstitial spaces of lungs; caused by HF (left), fluid overload (IV fluids), prolonged airway obstruction, sepsis, aspiration control pain get them up and moving What are your top two priorities with postop pt? pneumonia; decreased lung expansion atelectasis may lead to mucus plugs, hypoventilation, constant recumbent position, ineffective coughing, Hx of smoking What are some contributions to atelectasis? incentive spirometer deep breathing while encouraging coughing, 10 breaths every 1 hr while awake, TCDB, ambulation fluid nad electrolyte imbalances, fluid retention, fluid overload what are some potential circulatory problems? monitor VS, leg exercises, early ambulation, prophylactic DVT treatment, TED hose What are some management options we can do for potential circulatory problems? 2 hours How long does Vancomycin take to go in (IV)? emergent delerium agitation and disorientation caused by hypoxemia or a reaction to anesthetic agents; neurological complication delayed awakening prolonged drug reaction due to narcotics, sedatives, or anesthetics; neurological complication fluid/electrolyte imbalances, drug effects, sleep deprivation, alcohol withdrawal What are some potential neurologic complications in older pts? environmental aids, listening and talking with pt What are some ways we can manage potential neurologic complications? breathing Pt is in acute pain and having trouble breathing- what's your priority? acute pain treated with opioid analgesics, IV/PCA in PACU, fentanyl citrate (Sublimaze), morphine sulfate, meperidine hydrochloride (Demerol), has rapid onset skin/tissue trauma, muscle spasms around incision, postop movement, full bladder, anxiety complicates the pain threshold What are some causes of pain? measure pain before and after treatment, observe for indications of pain and question the degree and characteristics of the pain What are some important things JACO standards of practice include about pain? false-can be anywhere your pt comes back from surgery and complains of pain in their shoulder, but their surgery was on their ankle. T/F: pain is only at the surgical site. PCA pumps this is analgesia pump is controlled by the pt; self-administered pre-determined doses; basal rate constant, steady rate epidural analgesia this is when a catheter is placed in the epidural space surrounding the spinal cord; delivers meds directly to the opiate receptors in the spinal cord; common drugs used are opioids, fentanyl along with local anesthetics (sensorcaine) don't slide- pick up and move your pt has an epidural taped down well on their back, but what is something to teach the patient to avoid getting it moved or ripped out? sedation, respiratory depression (stimulation or Narcan), N/V (antiemetics), constipation (stool softener/laxative), itching (antihistamine-Benadryl) What are some SE of PCA/epidural analgesia and how can we treat those symptoms? comfort measures, splint incision, bend knees (decrease tension on incision), reuniting pt and family, rewarming of the pt What are some nursing interventions for the SE of PCA/epidural analgesia? hypothermia temp 96.8 F (36 C), most common in older/debilitated/intoxicated, anesthetic agents can alte