Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates, Study Guides, Projects, Research of Nursing

Download Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates and more Study Guides, Projects, Research Nursing in PDF only on Docsity! Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 Focus points for Exam 1 Medical Surgical Nursing Lab Values Pre- Albumin Levels – Nutritional status, very specific Dehiscence – partial or complete separation of the outer wound layers and sometimes described as splitting open of the wound - What to do for it – recover the open section of the wound with a steri-strip - Often occurs in obese patients and those with diabetes, immune deficiency or malnutrition or those on steroids. - Notify the doctor Surgical Risk Factors - Age older than 65 - Medications o Antihypertensives Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 Magnesium 1.7-2.2 BUN (Blood Urea Nitrogen) 7-20 Creatine Kinase – presence of muscle trauma or disease INR 2-3 Alkaline Phosphatase Presence of bone trauma or disease WBC 4.5-10 thousand/mm 3 Chloride 95-105 RBC Female 4-5.0 million /mm3 BUN/Cr Ratio 6-25 Platelets 150-400 thousand/mm3 Hemoglobin female 12-15 Potassium 3.5-5 Carbon Dioxide 22-30 RBC Male 4.6-6.0 million /mm3 Sodium 135-145 Hematocrit Female 36-46% Hemoglobin male 13.5-18 Creatine 0.5 -1.2 Phosphorus 2.5-4.5 Minimum Urine Output/hr 30ml/hr CRP/ESR Inflammation bio-markers Hematocrit male 40-54% Fasting blood glucose 70-110 Calcium 9-11 Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 o Tricyclic antidepressants o Anticoagulants o NSAIDS o Immunosuppressive - Medical History o Decreased immunity o Diabetes o Pulmonary disease o Hemodynamic instability o Multi system disease o Any chronic disease o Coagulation defect or disorder o Infection o Hypertension o Hypotension - Prior Surgical experiences o Less than optimal reaction o Anesthesia reactions or complications o Post operation complications - Health History o Malnutrition or obesity o Drug, tobacco, alcohol or illicit substance use or abuse o Altered coping ability o Herbal use o Allergies - Family History o Malignant hyperthermia o Cancer o Bleeding disorder o Anesthesia reactions or complications - Type of surgical procedure planned o Neck, oral, or facial procedures (airway complications) o Chest or high abdominal procedures (pulmonary complications) Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 most reliable source is what the patient says it Side effects of Opioids - Constipation o What does the nurse do about this ▪ Assess previous bowel habits ▪ Keep a record of bowel movements ▪ Remind patients that tolerance to this side effect does not develop so a preventive approach must be used; administer a stool softener plus mild stimulant laxative for duration of opioid therapy; do not give bulk laxatives because these can result in obstruction in some patients ▪ Provide privacy, encourage adequate fluids and activity, and give foods high in roughage ▪ If ineffective, try suppository or fleets enema ▪ For long term opioid-induced constipation in patients with chronic pain, drug therapy may be used(e.g lubiprostone (amitiza), methylnaltrexone (Relistor) - Nausea/vomiting ▪ Use a multimodal antiemetic preventive approach ▪ Assess cause of nausea and eliminate contributing factors if possible ▪ Reduce opioid dose if possible ▪ Reassure patients taking long term opioid therapy that tolerance to this side effect develops with regular daily opioid doses ▪ Treat with antiemetic drug as prescribed ▪ Consider switching to another opioid for unresolved N/V - Sedati on ▪ Remember that sedation precedes opioids – induced respirator depression; identify patient and iatrogenic risk factors and monitor sedation level and respiratory status frequently during the first 24 hours of opioid therapy ▪ Use a simple sedation scale to monitor for unwanted sedation Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 ▪ If excessive sedation is detected reduce opioid dose to prevent respiratory depression ▪ Eliminate unnecessary sedating drugs such as antihistamines, anxiolytics, muscle relaxants and hypnotics. If necessary to administer these drugs during opioid therapy, monitor sedation and respiratory status closely ▪ Reassure patients taking long term opioid therapy that tolerance to this side effect develops with regular daily opioid doses ▪ Be aware that stimulants such as caffeine may counteract opioid-induced sedation ▪ Consider switch to another opioid for unresolved excessive sedation during long term opioid therapy - Respiratory depression ▪ Be aware that counting respiratory rate alone does not constitute a comprehensive respiratory assessment . proper assessment of respiratory Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 status includes observing the rise and fall of the patients chest to determine depth and quality in addition to counting respiratory rate for 60 seconds ▪ Recognize that snoring is a respiratory obstruction and an ominous sign ▪ Remember that sedation precedes opioid-induced respiratory depression; identify patient and iatrogenic risk factors and monitor sedation level and respiratory status frequently during the first 24 hours of opioid therapy ▪ Stop opioid administration immediately for clinically significant respiratory depression, stay with the patient continue attempts to arouse patient, support respirations call for help (consider rapid response team or code blue) and consider giving naloxone ▪ Reassure patients taking long term opioid therapy that tolerance to this side effect develops with regular daily opioid doses o Pasero Opioid-Induced Sedation Scale (POSS) with interventions ▪ S = sleep, easy to arouse ▪ Acceptable, no action necessary; may increase opioid dose if needed • 1. Awake and alert o Acceptable ; no action necessary; may increase opioid dose if needed • 2. Slightly drowsy, arousable drifts off to sleep during conversation o Acceptable ; no action necessary; may increase opioid dose if needed • 3. Frequently drowsy, arousable drifts off to sleep during conversation o Unacceptable – monitor respirator status and sedation level closely until sedation level is stable at less than 3 and respirator status is satisfactory; decrease opioid dose 25% to 50% or notify primary or anesthesia provider for Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 • Responsive to voice • Responsive to pain • Unresponsive - Lab values. Know what does it mean if they are elevated or depressed. Look at the electrolytes : what did we discuss if selected ones where abnormal, what body system would they affect o Potassium (K+) – 3.5-5 mEq/L ▪ Cardiac • Hypokalemia – a serum potassium level below 3.5 mEq/L o Can be life threating because every body system is affected • Hyperkalemia – serum potassium level above 5.0 mEq/L o can lead to heart block Ventricular fibrillation o Sodium (Na+) – 135-145 mEq/L ▪ Hydration Status and Brain • Hyponatremia – serum sodium level is below 136 mEq/L o Affects the cerebral, neuromuscular, and intestinal smooth muscle and cardiovascular functions • Hypernatremia – serum sodium level over 145 mEq/L o Altered cerebral function and dehydration o Chloride (Cl) – 95 – 105 mEq/L ▪ Gut ▪ Imbalance from other electrolytes except with excessive vomiting or prolonged gastric suction o Calcium (Ca+) – 9-11 mg/dL ▪ Bone & muscle • Hypercalcemia – is a total serum calcium level above 10.5 Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 mg/dL o Causes excitable tissues to be less sensitive to normal stimuli, thus requiring stronger stimulus to function ▪ The excitable tissues affected by most hypercalcemia are the heart, skeletal muscles, nerves and intestinal smooth muscles • Hypocalcemia – total serum calcium level below 9.0 mg/dL o Frequent report of frequent painful muscle spasms in the calf or the foot during rest or sleep o Over stimulation of the nerves and muscles o Occur first in the hands and feet o Phosphorus (Phos) – 2.5 -4.5 mg/dL ▪ Hyperphosphatemia - serum phosphate greater than 4.5 mg/dl • Increased membrane excitability leading to life threating side effects ▪ Hypophosphatemia – serum phosphate less than 2.5 mg/dl • Cardiac, musculoskeletal, hematologic, CNS Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 o Magnesium (Mag) – 1.7 – 2.2 mg/dL ▪ Bones & Cartilage • Intracellular fluid, more functions inside the cells than the blood o Important for skeletal muscle contraction, carbohydrate, metabolism, generation of energy stores, vitamin activation, blood coagulation, and cell growth ▪ Hypomagnesemia – is a serum magnesium level below 1.8 mEq/L • Caused by decreased absorption of dietary magnesium or increased kidney magnesium excretion o Two major cause of hypomagnesemia are inadequate intake and the use of loop or thiazide diuretics ▪ Hypermagnesemia – is a serum magnesium level above 2.6 mEq/L • Reduced membrane excitability o Bradycardia, peripheral vasodilation and hypotension (Cardiac) ▪ Patients with severe hypermagnesemia are in grave danger of cardiac arrest o CNS – depressed nerve transmission o Neuromuscular -reduced or absent deep tendon reflexes - Quality and Safety Education of nurses o Patient centered care ▪ Recognize the patient or the designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patients Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 ▪ Decreased ability to adjust to changes in surroundings o Musculoskeletal System ▪ Increased incidence of deformities related to osteoporosis or arthritis o Skin ▪ dry with less subcutaneous fat makes the skin at greater risk for damage; slower skin healing increases risk for infection - Shorter hospital stays – what does that require us to educate on o Self-care o Medication o Infection - Purpose of deep breathing/coughing post-operatively o Coughing to expel secretions, keep the lungs clear allow full aeration and prevent pneumonia o Deep breathing keeps your lungs well-inflated and healthy while you heal and helps prevent lung problems, like pneumonia. - What does NPO mean o Not by mouth - Evisceration : What do I do about it o Is the total separation of all wound layers and protrusion of internal organs through the open wound ▪ Is a surgical emergency; the surgeon is contacted immediately and the patient is returned to the OR. • What to do o Monitor risk factors o If wound evisceration occurs, call for help stay with the client, cover the wound with a sterile towel or dressing that is moistened with sterile Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 saline place in a low-fowlers position with hips and knees bent monitor for shock and notify provider immediately. Do not attempt to reinsert organs - Conscious Sedation : is the patient conscious ? Awake ? Asleep? Alert ? Unconscious o The patient is sleepy, awake, but not alert o Is the Iv delivery of sedative, hypnotic and opioid drugs to reduce sensory perception but allow the patient to maintain a patent airway o Moderate sedation is used to reduce the level of consciousness during minor surgical procedures, endoscopy, cardiac catheterization, closed fracture reduction and cardioversion - Post -op complications : prevention, early ambulation is key to preventing most o Other complication : DVT, pneumonia, PE, Paralytic ileus, Infections - Malignant hyperthermia o An inherited muscle disorder is acute, life threating complication of certain drugs used for general anesthesia ▪ Its characterized by many problems including inadequate thermoregulation ▪ The reaction begins in skeletal muscles exposed to the drugs, causing increased calcium levels in muscle cells Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 and increased muscle metabolism ▪ May start immediately after anesthesia induction several hours into the procedure, or even after anesthesia is completed • Symptoms, caused by increased muscle calcium and increased metabolism, include tachycardia, dysrhythmias muscle rigidity of the jaw and upper chest, hypotension, tachypnea, skin mottling cyanosis - Informed consent Nurse vs. MD Role o The nurse shall not obtain the consent for the provider in any circumstance o The nurse may not provide any information not previously given by the provider ▪ The nurses role is to witness the client signing of the consent form after the client acknowledges understanding of the procedure o The nurse should determine if the client is ▪ 18 years of age or emancipated ▪ mentally capable of understanding the risks, reason, and options for surgery and anesthesia ▪ Under the influence of medication that affects decision-making or judgement o Informed consent is required for surgical procedures invasive procedures and any procedure requiring sedation or anesthesia involving radiation or that places the client at an increased risk for complications o The providers role ▪ Obtain the informed consent ▪ Complete description of the treatment/procedure ▪ Description of the professionals who will be performing and participating in the treatment ▪ Information on the risks of anesthesia ▪ Description of the anticipated benefits of the treatment/procedure Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 o Never remove the surgical dressing- doctor does it the first time.. you don’t know what is under it. If drainage is on the dressing, outline it with a sharpie when you begin you shift, date and time it, then if it seeps outside the borders you know its still draining and how much. If dressing completely saturated: Reinforce with a new dressing overtop the saturated one, call the doctor he needs to come look at it, Only change dressing after MD has changed first surgical dressing postoperatively. Few exceptions C-section dressings - Drainage System Open vs. closed systems o T-tube –Closed wound drainage system –specialty drain placed for specific drainage purposes ▪ Drains bile after a cholecystectomy o Jackson Prat – closed wound drainage system o Hemovac –closed wound drainage system o Open wound drainage system ▪ Gravity wound drainage system ▪ Penrose – open o Closed suction drains such as Hemovac, VacuDrain, and Jacson Pratt drains include a reservoir that collects drainage - Medications o Ketorlac – Classification is NSAID, Do not give (contraindicated in patients with history of GI bleed or allergy to ASA (aspirin) Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 Note: ASA is a salicylate however; you will often see it in the Category of NSAID (It is not an NSAID but act likes one ) o Cefazolin (Generic Name) ▪ Brand name – Ancef ▪ Prevents skin and skin structure infections in orthopedic and general surgeries and is associated with lower risk of mortality in older adult patients ▪ Nursing implications • Patients with beta-lactam allergies receive vancomycin or clindamycin ▪ Classification – Antibiotic ▪ Used for the treatment of a number of bacterial infections • Cellulitis • UTI • Pneumonia • Endocarditis • Joint infections • Biliary tract infections • Perioperative prophylaxis • Genital infections • Bacterial endocarditis • Prophylaxis for dental • Upper respiratory tract procedures ▪ Do not give to people with a History of anaphylaxis to penicillin o Flumzenil (Generic Name) ▪ Brand Name – Romazicon ▪ Reverses the effects of benzodiazepine sedatives such as Valium, Versed, Xanax, Tranxene ▪ Drug Class : Benzodiazepine antagonist o Naloxolone (Generic Name) ▪ Brand name – Narcan ▪ Use with opioid overdosing ▪ Drug class – opioid antagonist Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023 o Morphine (Generic Name) ▪ Brand Name: Morphine • Decreases anxiety provides analgesia ▪ Severe pain ▪ Pain is severe enough to require daily use ▪ Around the clock long term opioid treatment ▪ Binds to opioid receptors in the CNS ▪ Decreases the severity of pain ▪ Is the standard against which all opioid drugs are compared ▪ Has a slow onset and long duration ▪ Nurse implications • Monitor respiratory rate and blood pressure because respiratory depression can be severe and require medical intervention • Monitor GI motility and urine output because constipation and urinary retention can occur o Ondansetron (Generic Name ) ▪ Brand Name : Zofran ▪ Prevention of Nausea and Vomiting post-operative o ASA (Generic Name) ▪ Brand Name: Aspirin ▪ What reason not to give • In patients with hepatic risk factors • Chronic inflammatory pain (rheumatoid arthritis) o Cimetidine (Generic Name ) ▪ Brand Name : Tagamet • Dealing with volume concentration Focus points for Exam 1 Medical Surgical Nursing26 Best Exam Solution With Latest Updates 2022/2023