Exam 1 Study Guide Medical Surgical Nursing II

Medical Surgical Nursing II Exam 1 Study Guide Pain Management Pain pg 225-an unpleasant sensory and emotional experience associated w/actual or potential tissue damage. Types of pain pg. 225-227 Acute- less than 6 mos: surgery, trauma, burns Chronic- persistent, 6 mos or more: cancer or non-cancer Breakthrough pain- acute exacerbations of pain periodically Nociceptive- (physiologic) normal functioning of physiologic systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Nociceptive pain can be: somatic arises from the bone joint, muscle, skin, connective tissue or visceral arises from visceral organs, GI tract and pancreas Neuropathy pg. 226-227 Neuropathy pathophysiologic is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the peripheral or central nervous system or both. Transduction-noxious stimuli activate Transmission- transmit the info of pain to the brain Perception- the result of neural activity associated w/transmission of noxious stimuli Modulation- what happens after this info is generated “pull foot away” 1 Pain assessment/ Re-assessment pg. 230 the pt’s self report is the best indicator of pain. Pain assessment should be done during the admission, or initial interview, with each new report of pain, and whenever there is a change in the pt’s condition or treatment plan. “COLDSPA” Pain assessment tools pg. 230-231 Numeric 0-10 Wong Baker Faces-6 cartoon faces with word descriptions 0,2,4,6,8,10 pt is asked to choose the face that describes their pain. Used in adults and children as young as 3 yrs old. Faces- 6 faces 0,2,4,6,8,10 Used in children as young as 3 yrs old, however full ability to identify not until 8 yrs old. Verbal descriptor- uses different words and phrases to describe the intensity of pain such as no pain, mild, moderate, severe, very severe, worst possible, etc. Visual Analog Scale- 10cm line with word anchors at the extremes no pain on one end and pain as bad as it could be on the other end. Pt is asked to mark on the line to indicate intensity of pain. Length is then measured and recorded in cm or mm. Routes of administration for pain meds pg. 233 Oral route- preferred route, least expensive, best tolerated, easy to administer IV route- used in immediate post op period. Rectal route- used when oral/IV is are not an option. Contraindicated in pt’s who are neutropenic or thrombocytopenic b/c the potential of rectal bleeding. Also contraindicated: Diarrhea, perianal abscess or fistula. Topical route- produce effects in the tissues immediately under the site of application. Used in both acute and chronic pain. Eg. EMLA cream 2 Transdermal route- requires absorption into the systemic circulation to achieve effects. Eg. Fentynl change patch every 48-72 hrs; not used for acute pain Intraspinal route-inserting a needle in the subarachnoid space or the epidural space. Temporary epidural cathethers for acute pain are removed every 2-4 days. Patient Controlled Analgesia aka PCA pg. 234 Allows pt’s to treat their pain by self-administering the doses. It is sometimes used for pt’s who are opioid naïve and receiving IV PCA. Opioid naïve-pt’s are not chronically receiving opioids on a daily basis. Opioid tolerant- pt’s are chronically receiving on a daily basis Around the clock (ATC) pg. 234 – pain control for pain that is present 12 hrs or more during a 24 hr period. PRN pain medication regimen- as needed Physical dependence versus Tolerance pg. 238 Physical dependence- occurs with repeated administration of a drug for 2 or more weeks. Manifested by withdrawl sympoms when the drug is suddenly stopped or rapidly reduced. Tolerance- occurs in the first days to 2 weeks of opioid therapy but is uncommon after that. (Medication has no effect) May be treated w/ an increase dose Opioid Induced Hyperalgesia pg. 239- a paradoxical situation where increase opioid dose results in increase sensitivity to pain. Hyperplasia means sensitive to pain. Analgesics used for pain management Non-opioid 3 Opioids: Morphine first line, produces effects for up to 48 hrs, hydrophilic drug (absorbed in aqueous solution) Fentanyl (Sublimaze)- lipophilic drug (absorbed in fatty tissue), fast onset & slow duration Hydromorphone (Dilaudid)- second to morphine Oxycodone- in the U.S. Oral route only Oxymorphone- must be taken on an empty stomach 1 hr before or 2 hrs after a meal. Hydrocodone- available only in combination w/ non-opioids Methadone (Dolophine)- has a very long and highly variable half life, good tx of addictive disease, long acting Tramadol- used for both acute and chronic pain, can lower seizure threshold Opioids to avoid: Codeine, Meperidine (Demerol), Propoxyphene (Darvon) Adverse effects of opioids: constipation, n/v, pruritus, respiratory depression (rare), hypotension, sedation, delayed gastric emptying, slowed bowel motility, decreased peristalsis. Risk elevated w/ age. Adjuvants pg. 243 NSAIDS- Used for mild-moderate pain. Works by inhibiting the activity of COX-1 OR COX-2. Stop your body from making as many prostaglandins; this means less swelling and pain. Side Effects- Kidney damage (Nephrotoxicity), GI upset, High blood pressure Acetaminophen: Used for mild pain. Relieves pain by blocking your brain from releasing substances that cause the feeling of pain and reduces fever (antipyretic). Max dose 4000 mg/per day Side effects- Hepatic (liver failure), Ototoxic Local versus general anesthetics: “aine” versus “Ane” 4 Local pg. 449 numbs a small area, used in minor procedures, injected into the tissues at the planned incision site. General pg. 443 affects the entire body and makes the pt unconscious. Pt is completely unaware of what is going on and does not feel pain. Has 4 stages: Stage 1- (beginning anesthesia) dizziness and a feeling of detachment during induction Stage 2- (excitement) struggling, shouting, laughing, talking, singing, or crying Stage 3- (surgical anesthesia) the patient is unconscious and lies quietly on the table Stage 4- (medullary depression) if too much anesthesia is given; RR become shallow, pulse is weak and thread, pupils become widely dilated Neuromuscular junction blockers-drugs that interrupt transmission of nerve impulses at the skeletal neuromuscular junction. Eg. Succinylcholine Centrally acting muscle relaxant- works in the brain and spinal cord to block or dampen down excessively stimulated nerve pathways eg: Baclofen, Methocarbamol, Tizanidine direct acting muscle relaxants- acts directly on muscle fibers and are peripherally acting. Eg. Dantrolene Migraine medications pg.2006: periodic and recurrent attacks of severe headaches lasting from hours to days in adults. Medical mgnt pg.2007- 100% 02 by facemask for 15 minutes, subcutaneous sumatriptan, or intranasal zolmitriptan. NI for migraine pg. 2007- goal is pain relief. First priority is to treat the acute event of the headache and the second is to prevent recurrent episodes Moderate/Conscious sedation pg 448-449: pt is able to maintain a patent airway, retain protective airway reflexes, and respond to verbal and physical stimuli 5 medications used: Midazolam (Versed) reason for use- to reduce pt anxiety and control pain during procedures Neurological System Diagnostic tests used in neurological disorders: NI pre, intra and post SEE CHART Neuro assessment: Reflexes pg. 1963 Biceps reflex-normal response is flexion at the elbow and contraction of the biceps. Triceps reflex- Arm is flexed at the elbow and hang freely at the side; a direct blow on the tendon normally produces contraction of the triceps muscle and extension of the elbow. Brachioradialis reflex-With the pt’s forearm resting on the lap or across the abdomen; a gentle strike of the hammer 2.5-5 cm (1-2 in) above the wrist results in flexion and supination of the forearm. Patellar reflex- Strike the patellar tendon just below the patella. Contractions of the quadriceps and knee extension are normal responses. Achilles reflex- Foot is dorsiflexed at the ankle and the hammer strikes the achilles tendon. Normally produces plantar flexion Deep Tendon Reflexes pg. 1962 0 no response 1+ Diminishes (hypoactive) 2+ Normal 3+ Increased 4+ Hyperactive (hyperreflexia) CNs SEE CHART GCS pg 2042 6 13-15 minor injury 9-12 moderate injury 8 or less severe head injury *GCS=VEM Verbal response, Eye-opening, motor response* score 3-15 Cerebellar function pg.1949- posterior to the midbrain and pons, and below the occipital lobe. Integrates sensory information to provide smooth coordinated movement. It controls fine movement, balance, and proprioception (awareness of position) cerebral function pg. 1948- Cerebrum is largest part of the brain and has 2 hemispheres right and left. “LEFT LANGUAGE-RIGHT RECKLESS” Interprets touch, vision and hearing, speech, reasoning, emotions, learning, and fine control of movement. Frontal lobe-abstract thought, storage/memory Parietal Lobe- analyzes and relays information Temporal Lobe- auditory receptive areas, understanding language and music Occipital-visual interpretation and memory Head Injury pg 2038 Injury to scalp, skull, brain 3 cardinal signs: coma, absence of brainstem reflexes, apnea Skull fractures: Open fracture- scalp laceration or tear; penetrating trauma Closed fracture- dura is intact; blunt trauma Linear fracture-break in the continuity of the bone. Bedrest & observation Comminuted fracture-splintered or multiple fracture line. Surgery within 24 hrs 7 Depressed fracture pg. 2035-Bones of the skull are displaced downward. Requires surgery with elevation within 24 hours of injury Basilar fracture- fracture at the base of the skull. s/s traverse the paranasal sinus of the frontal bone or middle ear. Hemorrhage of the nose, pharynx, ears, under conjunctiva, ecchymosis (bruising) over the mastoid (Battle sign), rhinorrhea, otorrhea, raccoon eyes NO SURGERY UNLESS LEAKING CSF MEDS: DEXAMETHASONE, ABT CT or MRI to dx skull fracture Nursing Mgnt: observe for bleeding, test ear drainage/sinus for glucose, keep ear/nose clean, use sterile technique. Instruct pt not to blow nose, cough, sneeze. Halo sign s/s: vomiting, drowsiness, difficulty walking, blurred vision, slurred speech, h/a,stiff neck, seizures Brain injury pg. 2036-2037 Concussion- temporary loss of neurologic function w/no apparent structural damage; direct blow, blast injury Contusion- brain is bruised and damaged in a specific area. Loss of consciousness w/stupor and confusion. Coup Contre Coup- associated w/cerebral contusions. Coup-moving object strikes a stationary head Contrecoup-moving head (brain) strikes a stationary object. Diffuse Axonal Injury pg. 2037 8 Results from widespread shearing and rotational forces that produce damage throughout the brain. Prolonged traumatic coma, immediate coma, decorticate and decerebrate posturing. Intracranial Hemorrhage pg. 2036- collection of blood in the brain Epidural-above the dura Subdural-below the dura Intracerebral-within the brain Treatment: Decorticate pg. 1974- abnormal flexion of the upper extremities, internal rotation of the lower extremities, plantar flexion of feet. Decerebrate pg. 1974- extreme extension and outward rotation of upper and lower extremities and plantar flexion of feet. Increased ICP Cushing’s reflex pg. 1980 aka vasopressor response- response to increase ICP that results in the cushing’s traid (bradycardia, HTN, bradypnea) Medication treatment: osmotic diuretics, restricting fluids, drain CSF, control fever, stool softener, Nursing Interventions pg. 1984, 1987- patent airway, listen to lungs every 8 hrs, elevate HOB, keep HOB 30-45 degrees in neutral position, proper positioning, decrease ICP, maintain BP/O2, suction no more than 15 sec, Spinal Cord Injury: Levels, S/S, treatment/ medications, NI pg. 2048 loss of motor function, sensation, reflex activity, and bowel and bladder control, behavior and emotional problems. four primary mechanisms that may result in spinal cord injury: hyperflexion, hyperextension, axial loading or vertical compression, excessive rotation SCI Risk factors: younger age, male gender, alcohol & drug abuse S/S of SCINI of SCI- immobilize pt on spinal back board w/head & neck maintained in neutral position. Stabilize w/Halo traction, monitor respiratory, Gardner wells 9 tongs, skin integrity, assist w/quad coughing, bowel/bladder training, monitor for ascending edema. Medications: corticosteroids, vasopressors, antispasmodics, analgesics, TCAs Diagnostics- lateral cervical spine x-rays, CT, MRI, EMG after acute injury to locate level of injury. Complete SCI- spinal cord has been severed or damaged in a way that eliminates all innervation below the level of injury (CAN NOT MOVE AT ALL) Incomplete SCI – injury that allows some function or movement below the level of injury (CAN MOVE A LITTLE BIT) SCI Levels see pg. 2048, 2052 Autonomic Dysreflexia (Autonomic Hyperreflexia) pg.2057 Life-threatening emergency. Exaggerated sympathetic response that occurs with clients with T6 injuries or higher. It occurs only after spinal shock has resolved. excessive, uncontrolled sympathetic output S/S: sudden onset of severe, throbbing headache, severe rapidly occurring hypertension, bradycardia, flushing above level of lesion (face and chest), pale extremities below level of lesion, nasal stuffiness, sweating, nausea, blurred vision, piloerection, feeling of apprehension Four keys to remember: Restrictive clothing Pressure areas Full bladder or UTI Fecal impaction NI: place patient in sitting position (FIRST PRIORITY), page/notify health care provider, loosen tight clothing, assess and treat cause, check urinary catheter tube for kinks, check for bladder distension (if no catheter, Cath patient immediately), check room temp to ensure its not too cool, monitor bp every 1015 min, give nitrates as prescribed Spinal shock pg. 2053 Immediate temporary loss of total power, sensation and reflexes below the level of injury (areflexia). 10 Tetraplegia pg. 2048 – paralysis of all four extremities aka quadriplegia Paraplegia pg. 2048- paralysis of the lower body Hyperflexion in SCI - head is suddenly and forcefully accelerated, causing extreme flexion of neck. ligaments can be torn, and vertebrae dislocated or fractured (ex. head on vehicle collisions and driving accidents) Hyperextension in SCI- head is suddenly accelerated then decelerated, this stretches or tears ligaments, fractures vertebrae, ruptures disk. (ex. vehicle struck from behind or fall when patient's chin is struck) Axial Loading- caused by diving accidents, falls on buttocks, or a jump when a person lands on feet. a blow to the top of the head cause vertebrae to shatter, pieces of bone enter spinal canal and damage cord. Excessive Rotation- caused by turning head beyond normal limit range Brain Tumors pg. 2092 Can occur in any part of the brain and are classified according to the cell of tissue origin Primary malignant tumors- originate from neuroglia tissue and rarely metastasize outside the brain. Secondary malignant tumors- Lesions that are metastases from primary cancer located elsewhere in the body. Benign tumors- Develop in the meninges or cranial nerves and do not metastasize, they cause damage either by pressure or by impairing function of cranial nerves 11 S/S of tumors Dysarthria (slurred speech) Dysphagia (difficulty swallowing) Positive Romberg Positive Babinski Vertigo Hemiparesis (Muscle weakness, partial paralysis) Cranial nerve dysfunction Supratentorial- brain tumors occur in the cerebral hemispheres above the tentorium cerebelli s/s of Supratentorial tumors (above tentorium) severe h/a worse upon wakening gets better over time visual symptoms loss of voluntary movements change in cognitive functioning change in personality, inability to control emotions nausea with or without vomiting Infratentorial – brain tumors that are below the tentorium brain stem and cerebellum s/s of Infratentorial tumors (below tentorium) hearing loss facial drooping difficulty swallowing Nystagmus, cross-eyes, or decreased vision Autonomic nervous system dysfunction Ataxia or clumsy movements Hemiparesis Cranial nerve dysfunction Brain tumor Diagnostics: x-ray, CT, MRI, brain scan, PET, Cerebral angiography, Cerebral biopsy Brain tumor Medical management: non-opioid, corticosteroids, anticonvulsants, H2 antagonists, antiemetics 12 Craniotomy: A craniotomy is the surgical removal of part of the bone from the skull to expose the brain Pre op NI- pt education, stop ASA 72 hrs. prior, all OTC report to provider, living will & durable power of attorney in place, meds administered as prescribed antianxiety/muscle relaxants Post op NI- v/s, neuro assessment, GCS, elevate HOB to 30 degrees & placed in neutral position, pain controlled, no straining activities, monitor bleeding Complications: DI- large amounts of diluted urine are excreted due to deficiency in ADH. Hypothalamus has been damaged and can no longer regulate the release of ADH Tx: massive fluid replacement, monitor labs, replace essential nutrients SIADH- condition where fluid is retained as a result of an overproduction of vasopressin or ADH. Hypothalamus has been damaged and can no longer regulate the release of ADH TX; fluid restriction, DDAVP, tx, hyponatremia Parkinson’s Disease: SEE CONCEPT MAP Amylotrophic Lateral Sclerosis (ALS): SEE CONCEPT MAP Huntington’s Disease: SEE CONCEPT MAP Care of the unconscious patient/ Altered LOC Bend the top leg so both hip and knee are at right angles. Gently tilt their head back to keep the airway open. If breathing or pulse stops at any time, roll the person onto their back and begin CPR. If you think there is a spinal injury, leave the person where you found them (as long as breathing continues) Seizures: simple partial- A partial (focal) seizure happens when unusual electrical activity affects a small area of the brain. When the seizure does not affect awareness, it is known as a simple partial seizure. complex partial- Complex partial seizures refer to focal seizures that start in one hemisphere of the brain and are associated with impairment in consciousness. Complex partial seizures are now preferably called "focal impaired awareness seizure" or "focal onset impaired awareness seizure." 13