305 Exam 3 Study Guide

Exam 3 Study Guide Chapter 41 Oxygenation Chapter 48 Skin Integrity/Wound Care Chapter 50 Periop Nursing Care Chapter 44 Pain Management Chapter 17,18,19,20 Nursing Process Approx Q’s= 15 Approx Q’s= 15 Approx Q’s= 7 Approx Q’s= 8 Approx Q’s= 15 Total Q’s= 60 Chapter 41 Oxygenation: 1. Oxygen delivery devices (Table 41.7) 3_2023 2. Angina vs MI • • Angina Transient imbalance bet. myocardial oxygen supply and myocardial oxygen demand S/S o Chest pain o Aching/sharp/tinging/burning/pressure (L sided) o Radiates → jaw/arms/neck/back o Lasts 3-5 min precipitated by activity that ↑ O2 demand o Relieved by rest or nitroglycerin • • Myocardial Infarction (MI) Sudden ↓ of coronary blood OR ↑ in myocardial oxygen demand w/o adequate coronary perfusion S/S o Crushing/squeezing/stabbing in the chest/sternal area felt in the back o Radiated down L arm → neck/jaw/epigastric area/indigestion/shoulder o REST and MEDS DO NOT HELP 3. Factors affecting oxygenation, respiratory and cardiac functioning and Table 41.1 4. Responsibility of alveoli • • • Resp muscles, pleural spaces, lungs, alveoli (essential for ventilation, perfusion, and gas exchange) Exchange for resp gases (CO2 + O2) happens in the alveoli and goes to body tiss Nursing action to prevent complications (maintenance and promotion of lung expansion) o Ambulation, positioning, incentive spirometry (IS) 5. Hypoxia- Clinical manifestations (signs and symptoms) 3_2023 • Hypoxia- inadequate tiss oxygenation at the cellular lvl (can be fatal and cause heart dysrhythmias) o Causes § ↓ hemoglobin, ↓ oxy carrying cap, ↓ concen of inspired oxy, and ↓ diffusion of oxy from alveoli to the blood § Inability of the tiss to extract oxy from blood (cyanide poisoning) § Poor tiss perfusion w/ oxygenated blood (shock) § Impaired ventilation (rib frac, trauma) o S/S § Restless (early sign)* § Apprehensive § Inability to concen § LOC § Dizziness § Behavioral changes § ↑ HR and RR § Cyanosis (late sign)* 6. Right vs Left-sided Heart Failure • • • R sided HF Impaired func of R ventricle; amt of blood eject BACKS UP into circ sys Long term fx of L sided HF = R sided HF (think systemic backup) S/S o o o o • • Weight gain Distended neck veins Hepato- or spleno- megaly Peripheral edema L sided HF Amt of blood ejected from L ventricle ↓ greatly, blood begins to pool in pulmonary circ = ↓ cardiac output (think pulmonary backup) S/S o o o o o o o o o Fatigue Breathlessness Dizziness Confusion Pulmonary congestion (crackles) Hypoxia SOB on exertion Cough Paroxysmal nocturnal dyspnea 7. Dangers of Carbon Monoxide (Decreased oxygen-carrying capacity) • • 3_2023 Carbon monoxide (CO)- odorless, colorless gas that ↓ oxygen carrying capacity Hemoglobin will bind to CO and create a functional anemia; (hemoglobin + CO = func anemia) • • • Bc of the strength of the bond, CO does NOT easily dissociate from hemoglobin, making hemoglobin unavailable for oxygen transport Pt w/ CO poisoning are often UNAWARE of their exposure to this gas S/S (mimics other illnesses) o Headache o Dizziness o Nausea o Vomiting o Dyspnea 8. Tasks that can be delegated when applying oxygen (Box 41.9) • • Nurse is responsible for assessing the pt’s resp sys and response to oxygen therapy, may also collab w/ resp therapist to set up oxygen therapy (adjustment of oxy flow rate) Skill of applying a nasal cannula or oxygen mask can be delegated to AP AFTER the method of delivery and % of oxygen need by pt is det. They may also; 1. Safely adjust device (loosening stap on oxygen cannula or mask) and clarify its correct placement and positioning 2. Inform the nurse immediately about any changes in: VS, pulse ox (SpO2), LOC, skin irritation from cannula/mask/straps, pt complaints or SOB 3. Prov extra skin care around pt’s ears, nose, or other parts of pt’s body that might be irritated by the device 9. Different coughing and deep breathing techniques. Why they are used? What do they prevent? • 3_2023 Different coughing and deep breathing techniques helps maintain a patent (open) airway by a deliberate maneuver to remove secretions out from both upper and lower airways o Coughs § Huff cough- stim a natural cough reflex and is generally used to help move secretions to the larger airways; holds breath 2-3 sec while forcefully exhaling saying the words “huff” § Cascade- deep breath, holds breath 1-2 secs, then open mouth and performs a series of coughs • Often used in pts w/ large amts of sputum (cystic fibrosis CF) o Breathing § Diaphragmatic- encourages deep nasal inspiration to ↑ air flow to the lower lungs. The diaphragm (belly) moves out (descends) when breathing in and belly sinks in (ascends) when breathing out • For pts w/ COPD, this technique ↑ tidal volume and oxy sat, improves exchange of resp gases, and ↓ dyspnea • Supine position 1st → sitting → standing 10. Nursing implications for O2 administration for COPD patients • Use oxygen therapy CONSERVATIVELY otherwise, we’re suppressing their resp drive o Too much oxygen: pt becomes → hypoventilated § COPDers have become adapted to ↑ lvls of CO2, so it might affect them neg. o S/S: § Mental status changes § Dysrhythmias § Cardiac arrest § IF UNTREATED: convulsions, unconsciousness, death 11. Mobility and oxygenation (Table 41.6 positions for postural drainage) 3_2023 12. Health promotion to prevent respiratory infections • • • 3_2023 Vaccinations o Influenza, pneumococcal Healthy lifestyles o Elim risk factors, eating right, reg exercise o 150 min per week of moderate intensity; 2 days per week of musc strengthening o Avoid exertion in extreme temps Environ pollutants o 2ndhand smoke, work chem, and pollutants 3_2023 Chapter 48 Skin Integrity/Skin Wound: (table 48.5 Braden Scale- what is this tool used for?) (Fig 48.9bony prominences 1. Nursing action for prevention of pressure injuries (table 48.1 strategies to prevent medical and immobilization device-related pressure injuries, table 48.8 quick guide) 3_2023 3_2023 2. Pathogenesis for pressure injury development (and Box 48.1 skin associated issues) 3. Types of tissue (granulation, slough, eschar) • • • Granulation o Red, moist, comp of new blood vess o Sign of progression towards healing Slough o Vascular, moist tiss o Yellow, stringy sub att to wound bed which must be removed to allow healing (bad tiss) o Unstageable Eschar o Black, brown, necrotic (dead tiss) o Needs to be removed to allow healing o Unstageable 4. Types of wound drainage (Table 48.3) 1. 2. 3. 4. 3_2023 Serous- clear, watery plasma Purulent- thick, yellow, green, tan or brown Serosanguineous- pale, pink watery; mixture of clear and red fluid Sanguineous- bright red; indicates active bleeding 5. Nursing action for an eviscerated wound Evisceration- protrusion of visceral organs thru an opening – MED EMERGENCY – protocal for eviscerated wound 1. 2. 3. 4. Remain w/ pt Place sterile covering over wound Make pt NPO due to emergency surgery Call HCP + surgical team immediately 6. Nutrition required for wound healing (Table 48.6 Role of selected nutrients in wound healing) 3_2023 7. Delegation of skin/wound care (skill 48.1- yellow pages/back of chapter) Skill of press injury risk assessment cannot be delegated to AP. Instruct AP to: 1. Freq change pt’s position, and use specific positions individualized for the pt 2. Keep pt’s skin dry and prov hygiene following: o fecal/urinary incontinence o exposure of skin to wound 3. Report any changes in pt’s skin (redness, break in skin) 4. Report any redness/abrasion from medical devices Chapter 50 Perioperative Nursing Care: 1. Stages of surgery (periop, intraop, postop- what is the importance of each?) Perioperative • • • ID preop func Recog and prev/↓ postop complications Establish pt func and baseline Intraoperative • • Make sure pt doesn’t die Constantly reviews and modifies plan 1) Circulation Nurse • Manages nursing process - Constantly assessing pt - Diagnose if there is a prob - Prioritizing and planning - Performs nursing actions/interventions - Evaluates • Maintains pt safety • Skin prep • Admin meds • Counts surgical equip 2) Scrub nurse • Maintains sterility thruout process 3) RN 1st assistant • Prov duties for surgical team - Suturing, cutting tiss, helping wound management • APRN/CRNA 3_2023 Postoperative • Hand- off communication (SBAR) • Conduct complete sys assessments - sys performed during surgery • Once awake, expectorate the airway • Det pt status and readiness for discharge (based on VS) • Post Anesthesia Recovery Score (PARS) • Management of postop complications - fluid imbal - bleeding • Pain management 2. Surgical risk factors (know what they are and why they put your client at risk, table 50.3 Physiological factors that place the older adult at risk during surgery, table 50.4 Medical conditions that increase risks of surgery) • Surgical risks 1. Smoking o Mainly intraoperative and postop complications o ↑ risk of developing: § Pneumonia § Atelectasis § Delayed wound healing § Aspiration r/t ↑ inflammation of airway § ↑ difficulty of oxygen reaching cells 2. Age o Probs w/ temp ctrl for anesthesia is a risk for aged pts o Very young = ↑ risk for dehydration o Very old § Chronic health issues § Comorbidities and risk factors make them at risk for postop complications § ↓ cardiac func and resp func § Pulmonary, and renal dysfunc § Impaired func reserve of the pulmonary sys § ↓ cough reflex = ↑ aspiration, infx, and bronchospasm 3. Nutrition o Too thin, obese, or malnourished § Iss for correct energy stores for recovery § Wound healing (albumin important to fix this) 4. Obesity o Pneumonia o Atlelectasis o DVT o Poor nutrition 5. Obstructive Sleep Apnea (OSA) o Intra and postop complications o Narrowing of the airway/collapse of the airway that causes apnea (inability to take a functional breath) o Cannot expel CO2 o Not good BF/circ o Poor oxygenation 3_2023 o o Atelectasis DVTs 6. Immunosuppression o Prophylaxis (meds before and after surgery to ↓ infx) 7. Fluid and electrolyte imbalance o Surgery causes a natural imbalance 8. Postop nausea and vomiting o Fluid and electrolyte imbalance o Dehydration o Pulmonary aspiration 9. Venous thromboembolism (VTE) o Never event o VTE measures specific to hospital 3. Nursing actions to prevent post-operative complications (and table 50.8 Postoperative complications) • Maintain resp func o Semi-fowler o Incentive spirometry • Prev circ complications o ROM exercises o Pain meds • Promote early mobility o ↓ risk of DVT and length of stay • Achieve rest and comfort • Temp reg o Assessment of VS • Maintain neuro func o Maintain IV o Assess wound drainage • Promote norm GI func and adequate nutrition o Advance diet as tolerated • Promote urinary elim o Upright o I&O • Skin and wound care o Splinting (binders) • Maintain/enhance self-concept o Privacy 3_2023 o o o Hygiene Unpleasant odors Discussion and teaching 4. Purpose of Time-out procedure • Includes: surgeon, anesthesiologist, surgical techs, nurse, etc. • Stand around, make eye contact, and go thru important factors of the surgical procedures to ensure “never” events occur • Occurs BEFORE and DURING surgery 3_2023 • • • Must be verbalized so everyone can hear; must verbalize: o Pt’s 1st and last name o DOB o Allergies o Procedure being performed o Laterality of limb (L or R) o Consent form is completed o Pt has been prepped w/ proper anti-septic o Equipment and tool count o ALL NEEDS TO BE COMPLETED BEFORE SURGERY Can be done by surgeon or circulation nurse (team lead) All team members must be present and silent 5. Never Events • Never happen; usually preventable • Intraop nurse now w/ the preop nurse have both worked to prev those never events from occurring o Ex. Performing surgery on incorrect limb/body part, leaving med supplies inside pt, or VTE 6. Delegation of surgical care (skill 50.1 yellow pages/back of chapter) • Skills of preop teaching CANNOT be delegated to AP. The AP can: 1. Reinforce/help pts perform postop exercises 2. Any precautions or safety iss unique to pt (ex. fall risks, mobility limitations, bleeding precautions) 3. Informing the nurse of any identified concerns (ex. inability to perform exercise) The Nursing Process: 1. The nursing process and its relation to Clinical judgment • Critical thinking helps makes judgements and leads to nursing process 2. The parts of a nursing diagnosis (there are 3) NANDA/Nursing diagnosis • Language that separates nursing from medicine • Used to describe the characteristics of the human response ID’d 3_2023 • Related To (r/t) Etiology, circumstances, facts, influences that have a relationship to the diagnosis As Evidenced By (AEB) • Defining characteristics • Major assessment findings or defining characteristics that were used to select diagnosis 3. Creating a diagnosis from assessment (cluster) data • • • Look for defining characteristic or abnorm signs Gather groups of data together to find a pattern → most pertinent iss Assessment data = AEB 4. Purpose of a nursing diagnosis • Standardized verbiage that nurses use to describe a pt’s response or vulnerability to a health condition or a life event More info in #2^ • 5. What is data cluster? • • Set of assessment findings/defining characteristics Set of signs or symptoms that are grouped together in logical order 6. What is a defining characteristic? • • Things that highlight prob and are excellent indicators of priorities Observable assessment cues that cluster as manifestations of a problem-focused or health promotion nursing diagnosis Validates diagnosis • 7. What is etiology? • • Study of all factors that may involved in the development of a dis Related factor; causes 8. Goal versus outcome • • Create short-term outcomes to be able to meet a long-term goal Goals are broad/outcomes are smart 9. Collaborative vs independent vs dependent interventions • • 3_2023 Independent Initiated by nursing/autonomous Do NOT req. an order from another professional • Dependent Actions that req. an order from physician or other licensed professionals (PA, NP) o Ex. Medications* Collaborative (Interdendent) • Therapies that req. combined knowledge, skill, and expertise of mult. HCPs • Based on scientific rationale o Ex. TDBC, preventions, ADLS • Who do we work w/ that helps make the pts care better? o Ex. PT, RT, OT 10. Order of the nursing process (know old version and new version- what are the questions you ask?) New Nursing Process: 1. Assessment – [Recognize cues] • What matters most?* 2. Diagnosis – split into 2 • [Analyze cues]; giving cues meaning, what could it mean? • [Prioritize hypothesis]; taking abnormalities, give it meaning, now which is the most important? o Where do I start? o For ex. Airway is priority over constipation 3. Planning – [Generate solutions]; what can I do? 4. Implementation – [Take action]; what will I do? 5. Evaluation – [Evaluate outcomes]; what happened with our actions? What was the response? o Did it help? 3_2023 **many questions will be patient scenarios. From the info given you will need to determine: 1) what is the best diagnosis, or 2) what will be the best intervention, or 3) how will you evaluate the effectiveness** Chapter 44 Pain Management: 1. PQRST and OLD CARTS – during assessment 2. Biases and misconceptions of pain (Box 44.2 and table 44.4- save table 44.3 for peds) • Common biases and misconceptions (these statements are FALSE!!!) o Pts who abuse substances (drugs/alcohol) = overreact to discomfort o Pts w/ minor illnesses have LESS pain than those w/ severe physical alterations o Administering analgesics reg → drug addiction o Amt of tiss damage in an injury accurately indicates pain intensity o Health care personnel are the best authorities on the nature of a pt’s pain o Psychogenic pain is not real o Chronic pain is psychological o Pts who are hospitalized experience pain o Pts who cannot speak do not feel pain 3_2023 • Older Adults (44.4) • Kids (44.3) 2. Side effects of opioids (box 44.13) 3_2023 3_2023 3. Non-pharmacological pain management methods • Alone or in combo w/ meds o Cognitive and behavioral approach o Relaxation and guided imagery o Distraction o Music o Cutaneous stim (needs, orders) o Herbals o ↓ pain perception and reception (pain reporting is essential and freq for this reason) 4. Education for effective pain management • Educate on diff types of pain management therapy 1. What the provider has ordered for them 2. How to properly report pain 3. Several measures to achieve pain relief 6. Cultural influences on pain/pain perceptions (Box 44.4) 3_2023 7. Prioritizing a patient in pain (ABC’s, pain, safety) 1. 2. 3. 4. 5. Airway Breathing Circulation Pain Safety 8. Purpose of PCA (box 44.17) 3_2023 • PCA- drug delivery sys that allows pt to self admin prescribed meds/opioids and have more ctrl over their pain management w/ a push of a button. Gives pt more freedom in managing their pain w/ minimal risk of overdose; only pt should push the button • Delegable activities to a NAP regarding PCA use (skill 44.1, yellow pages/back of chapter) o Skill of PCA admin CANNOT be delegated to AP. The nurse directs them to: 1. Notify nurse if pt expresses change in status (unrelieved pain) or has difficulty awakening 2. Notify nurse if pt has Q’s about PCA process or equip 3. Never admin a PCA dose for the pt and to notify the nurse if anyone other than the pt is observed admin a dose for the pt 9. Barriers to effective pain management (box 44.19) • • • • • • • • Pt barriers Fear of addiction Worry about side fx Fear of tolerance (will not be there when I need it) Takes too many pills already Concern about not being a “good” pt May need more tests Suffering in silence is expected and needs to suffer to be cured Inadequate education 3_2023 • • • • • • • • HCP barriers Inadequate pain-assessment skills No pain management protocols available Concern w/ addiction or accidental overdose Concern w/ comorbid mental health conditions Opiophobia (fear of opioids) Fear of legal repercussions Belief that pts need to learn to live w/ pain Reluctance to deal w/ side fx of analgesics Health Care Sys barriers • Concern w/ creating addicts • Limitation in filling prescriptions • mail-order pharmacy restrictions • advanced practice nurses not used efficiently • Poor pain policies and procedures regarding pain management • Inadequate access to pain clinics • • • • • • • Reluctance to discuss pain Belief that pain is inevitable Fear of dis progression Believes HCP and nurses are doing all they can Forgets to take analgesics Fear of distracting HCPs from treating illness Believes HCPs have more important/sicker pts • • • • • • • Not believing pt’s report of pain Fear that giving dose will kill pt Time constraints Inadequate reimbursement Belief that opioids “mask symptoms” Belief that pain is part of aging Overstim of rates of resp depression • Poor understanding of economic impact of unrelieved pain 10. Chronic vs acute pain • • • • • 3_2023 Chronic Pain Not protective Serves no purpose Disrupts norm func ability 3-6+ months Types 1. Chronic episodic pain • Sporadically • Migraines 2. Idiopathic pain • Absence of an identifiable cuase • Don’t know where it’s coming from • • • • • Acute Pain Creates fight or flight response and body creates prot mechanism when experiencing this to prohibit from experiencing the “full breaths of the pain” Protective Short in duration Limited tiss damage <3 months