Med Surg Week 1 Lecture Notes | Exams Nursing | Docsity (2024)

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WEEK 1-MEDSURGE EXAM LECTURE NOTES Med Surg - Week 1 Chapter 17: PREOPERATIVE CARE • Different types of surgery (know the difference) - the art and science of treating diseases, injuries, and deformities by operation and instrumentation o ELECTIVE SURGERY- Maybe be a carefully planned event ▪ Inpatient ▪ Scheduled o EMERGENCY SURGERY- unexpected urgency ▪ Inpatient ▪ Required immediately o AMBULATORY SURGERY- same day or outpatient surgery ▪ Involves minimally invasive techniques (ex: laparoscopic techniques) ▪ Typically take place in endoscopy clinics, Dr.’s offices, surgical clinics ▪ Short recovery time ▪ Less complications ▪ Require less than a 24 hour stay • Patient education (include pain management, preventive measures to prevent complications, herbal supplements to avoid and rationale) o AVOID: astragalus and ginseng: Increase b/p before and during surgery o Garlic, vit e, ginkgo, and fish oils: increased bleeding o Kava and valerian: excessive sodium o STOP: all herbs and blood 2-3 weeks before surgery. Consult with PCP for specific instructions o TAKE: MVI until the day before, not on the day of to avoid possible nausea or vomiting after surgery o MEDICINE: Clopidrogel and aspirin or NSAID’s i.e. ibuprofen can increase bleeding o Food allergy: banana and kiwi: risk for latex allergy. Eggs or soybean oil: contraindications for use of propofol. o Patient teaching: o Pain management: ▪ Explain expected s/s and risk factors ▪ Specify frequency, do not wait to take pain meds o Incentive spirometer/ deep breathing and coughing ▪ Prevents atelectasis and PNA ▪ Emphasize this o Ambulatory prevents formation of clots (scd) ▪ Key to preventing clots o High protein food, high fiber, and foods high in vit. C ▪ Promotes healing o Evaluate patient’s ability to learn and comply with treatment plan o Symptoms of infection ▪ Inflammation ▪ Warmth ▪ Tenderness o If any wound drain: how to empty and record output, expected color of drainage • Pain assessment o PQRST ▪ P- PROVOKING ▪ QUALITY- (descriptive type of pain) ▪ Region/radiating ▪ SEVERITY- 0-10 WEEK 1-MEDSURGE EXAM LECTURE NOTES ▪ TIME • Main purpose of preoperative assessment and documentation of findings o Establish baseline o Identify risk factors o Plan care to ensure patient safety • Preoperative diagnostic tests o BMP o CBC- looking wbc elevation (increased WBC count over 10000) o ABG- evaluates blood gas levels o pH 7.25-7.45, bicarb 22-26, CO2 35-45, paO2 70-100, spO2 95-100 o Hgb: looking for anemia, (carries oxygen) o Liver function: ast and alt (metabolizes meds, breaks it down and takes what it needs) ▪ AST/ALT Increased by vaccine 1 week prior to surgery o Kidney function: can't excrete waste if there is a failure which causes toxicity o PPT/INR- (prothrombin time)- applies ot heparin o Diabetes keeps older patients from healing • *KNOW the Normal values of the following: WBC, platelet, Hgb, HCT, INR, BUN, Cr, K+, Na+ o WBC 5.2-12.4 o Platelet 130,000-400,000 o Hemoglobin 12.0-15.0 o HCT ▪ Female-37-47 ▪ Male-40-54 o INR (coumadin)- 0.9-1.2 o BUN 9-23 o Cr ▪ Female: 0.5-1.1 ▪ Male: 0.7-1.3 o K+ 3.5-5.0 o Na+ 135-145 • Language interpretation: o Use language line • Informed consent: Legal prep (permission can be withdrawn at any time by patient) o Verify patients are competent and oriented with what they are signing! o Check that all req. Forms are signed and chart ▪ Informed consent- always advocate for the patient, make sure documents are signed ▪ Blood transfusions ▪ Advanced directives ▪ Power of attorney • Allergy (food and medication) o Drug intolerance: results in unpleasant side effects but not usually life threatening o Allergy: Life threatening • Nursing assessment o Immune system- compromised immune system or use of immunosuppressive drugs can delay wound healing and increase risk for infection o Fluid and electrolytes: vomiting and diarrhea can cause imbalances and lose potassium (kayexalate), surgery delay can lead to dehydration o High potassium can result in cardiac arrest o Cardiac: be aware of hypertension, possible prophylactic (prevention) antibiotic WEEK 1-MEDSURGE EXAM LECTURE NOTES • Nursing management: pain, airway, and prevention of complications: ABC’s: airway, breathing and circulation o Change patient position every 1-2 hours o Early mobilization o Pain management o Adequate hydration (parenteral or oral) o Chest physical therapy- Airway clearance technique (percussion, vibration, deep breathing and coughing).Use of an incentive and spirometer to loosen secretions. • Potential Postoperative complications and nursing interventions o Neuropsychological: fever, hypothermia, pain, delirium o Gastrointestinal: delayed gastric emptying, distension & flatulence, hiccups, nausea & vomiting, postop ileus o Urinary: infection, retention o Respiratory: airway obstruction, aspiration, atelectasis, bronchospasm, hypoventilation, hypoxemia, pneumonia, pulmonary edema, pulmonary embolus. intervention: listen to lungs o Cardiovascular: dysrhythmias, hemorrhage, hypertension, hypotension, VTE, Syncope o Integumentary ( incision site): dehiscence, hematoma, infection o Fluid & electrolytes: acid-base disorders, electrolyte imbalances, fluid deficit, fluid overload. Most common: fluid deficit (BUN will be elevated if dehydrated) o Airway Obstruction: hypoxemia, atelectasis o Pulmonary Edema: aspiration, bronchospasm, hypoventilation o ALWAYS REVIEW PRE-OP LAB TESTS • Wound drainage device: nursing responsibilities and management • Importance of SCD and IS Chapter 11: Inflammation & Healing • Inflammatory Response: vascular response, cellular response, exudate formation o Vascular: if roger is activated to fibrin )strengthens clot formed by platelets) o Cellular: Chemotaxis (directional migration of WBC’s to site of injury) o Exudate formation: consists of fluid and leukocytes that move from circulation to the site of injury ▪ Serous- clear fluid ▪ Serosanguinous- blood ▪ Fibrinous ▪ Hemorrhagic ▪ Purulent- pus o Healing: • Clinical manifestation of inflammation *(select all apply) possibly on quiz* o Swelling o Redness o Heat o Pain o Loss of function • Stages of healing process (Repair and Regeneration) • RICE - rest, ice/ heat, compression and elevate o Initial phase- 3-5 days o Granulation- 5 days to 4 weeks. Wound is pink and vascular but friable. Fibroblasts migrate into site o Maturation- 7 days to several months. Colleges organized, see scarring, WEEK 1-MEDSURGE EXAM LECTURE NOTES o Secondary intention- wounds that occur from trauma, ulceration, and infection have extensive tissue loss. o Tertiary intention- delayed healing, occurs before or after infection is controlled. Resulting in a larger deeper scar. • Wound classification o Acute or chronic o Superficial • Complications of healing o Adhesions- Bands of scar tissue o Contractions- May cause deformity o Dehiscence- Separation of wound edges o Evisceration- Intestines protrude from wound o Excess granulation tissue- Extends above wound surface • Stages of Pressure Injury o Stage 1: intact skin with non blanchable redness of a localized area usually over honey prominences o Stage 2: partial thickness loss of dermis. Shallow, open wound with red pink wound bed. May be an intact or ruptured serum-filled or serosanguinous- filled blister. o Stage 3: full thickness skin loss, subcutaneous tissue may be visible but no bone, tendon, or muscle. Slough may be present. May have undermining or tunneling and wound depth varies by location. o Stage 4: Full thickness loss with bone, muscle tendon, or other supporting structures exposed. May have slough or Eschar o Unstageable: Full thickness skin or tissue loss (unknown depth) will have slough and eschar. KNOW 6 P’S. For checking circulation • PAIN: NOT RELIEVED BY INTERVENTION • PALLOR: PALE TOES OR FINGERS • POIKILOTHERMIA: COOL TO TOUCH • PULSES: PRESENT/ABSENT, STRONG WEAK • PARESTHESIA: SENSORY DEFICIT/TINGLING • PARALYSIS: LACK OF SENSATION/ MUSCLE WEAKNESS Acute pain is protective, temporary, usually self-limiting, and resolves with tissue healing. Treatment includes: treating the underlying condition. Chronic pain is not protective. It is ongoing or who occurs frequently, lasting longer than three months and persistent beyond tissue healing. Nociceptive pain arises from damage to or inflammation of tissue other than that of the peripheral and central nervous system. Throbbing, aching, and localized pain is managed using opioids and nonopioids pain medications. Neuropathic pain arises from abdominal or damaged nerve pain nerves; it includes phantom limb pain, pain below the level of the spinal cord, and diabetic neuropathy. Usually intense shooting burning and described as pins and needles. Treatment antidepressants, antispasmodic agents, skeletal muscle relaxants. PRACTICE QUESTIONS Approach each question asking yourself the following: What type of question is this? Airway Breathin g Circulatio n WEEK 1-MEDSURGE EXAM LECTURE NOTES Assess Diagnos e Plan Implement (Intervention) Evaluate PAIN MANAGEMENT 1. A nurse is caring for a client who is experiencing mild acute pain after spraining and ankle. Which of the following analgesics should the nurse expect to administer? a. Ketorolac* (minor pain) b. Ketamine (neuropathic) c. Meperidine (versed) - not recommended d. Methadone (severe pain) 2. A nurse at a clinic is talking with a client who has cancer and takes extended release opioids twice daily. The client reports an increase in localized, achy pain over the last few days. How should the nurse document this increase in pain? a. Phantom limb pain b. Mixed pain (fibromyalgia) c. Breakthrough pain* (acute exacerbation) d. Neuropathic pain (burning shooting, pins and needles). 3. A nurse is caring for a client who is receiving morphine via a patient controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following clients statements indicates that the client understands how to use this device? a. I’ll wait to use the device until it’s absolutely necessary. b. I’ll be careful about pushing the button so I don’t get an overdose. c. I should tell the nurse if the pain doesn’t stop after I use this device.* d. I’ll ask my son to push the dose button when I am sleeping. 4. A nurse is discussing pain assessment with a newly licensed nurse. Which of the following information should the nurse include? a. Most clients exaggerate their level of pain. b. Pain must have an identifiable source to justify the use of opioids. c. Objective data are essential in assessing pain. d. Pain is whatever the client says it is.* 5. A nurse is monitoring a client who is receiving opioid analgesia. Which of the following findings should the nurse identify as adverse effects of opioid analgesics? (select all that apply) a. Urinary incontinence b. Diarrhea c. Bradypnea* d. Orthostatic hypotension* e. Nausea* ANESTHESIA AND MODERATE SEDATION 1. A nurse administered meds alarm IV bolus to a client before your procedure. The client's blood pressure is 86/40 mmHg, and the heart rate is 134/min. Which of the following IV medication should the nurse administer? a. Naloxone (for opioids, reverses effects of resp depression). WEEK 1-MEDSURGE EXAM LECTURE NOTES 5. A nurse is caring for a client who reports nausea and vomiting two days postoperative following hysterectomy. Which of the following actions should the nurse perform first? a. Assess bowel sounds.* b.Administer antiemetic medication. c. Restarts prescribe IV fluids. d. Insert a prescribed nasal gastric tube. LECTURE BASED QUESTIONS 1. Which procedures are done for diagnostic purposes? (Select all that apply) a. Endoscopy b. Biopsy c. Hysterectomy d. Rhinoplasty e. Gastroscopy 2. What can potentially lead to complications during, or following a surgical procedure? (Select all that apply) a. Chronic kidney disease b. Cirrhosis c. bilateral amputation 10 years ago 3. A patient’s history reveals a history of atrial fibrillation and she disclosed that her mother died of a cardiac arrest at the age of 65 years old. What test will have to be done to evaluate the patient’s cardiac status and possible complications? (Select all that apply) a. Electrocardiogram b. PTI/INR c. blood glucose d. pregnancy test e. BUN and creatinine 4. The patient is being taken by the transporter to the OR for left knee arthroscopy. What actions should the nurse take at this time? (Select all that apply) a. Make sure that patient has the correct ID band and allergy band b. verify consent is signed. d. Complete the pre-operative nursing documentation. e. Make sure that the site is marked and initiated by the patient. 5. A patient scheduled for an elective hysterectomy tells the nurse, I am afraid that I will die in surgery like my mother did! Which initial response by the nurse is most appropriate? a. Tell me more about what happened to your mother b. Surgical techniques have improved in recent years c. You will receive medication to reduce your anxiety d. You should talk to the doctor again about the surgery 6. An 88-year-old patient arrived at the pre-operative unit and you are the RN who is assigned to the patient. Patient admitted to being so nervous when she was told by the surgeon about having to have surgery. She mentioned that she is taking Coumadin and just know it’s a blood thinner. You don’t see any proof that EKG was done on the patient before arriving at your unit. (Select all that apply) a.Asking the patient if she remembers who helped her at the doctors clinic. b. Check if there’s a pre-opt PT/INR, if none, draw specimen and sent to the lab at Stat c. Notify the surgeon and the anesthesiologist of the reason for delay. d. Perform a 12 lead EKG, report the results of the EKG to the anesthesiologist. WEEK 1-MEDSURGE EXAM LECTURE NOTES e. Ask the patient when was the last time she took her Coumadin. 7. A patient who has diabetes and use his insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which actions should the nurse take? a. Withhold the usual scheduled insulin dose because the patient is NPO and checked her blood sugar by finger-stick more often than usual before meals. b. Obtain a blood Cucos measurement before any insulin is administered. c. Give the patient a usual and some dollars because stress will increase the blood glucose. d. Give half the usual dose of insulin because there will be no oral intake before surgery 8. A nurse asked the patient to sign the consent form as specified by the surgeon and then signed the form after the patient herself. By action, what is the nurse doing? a. Verifying that the form consent is true volunteers in for one. b. Ensuring that the patient is mentally capable of signing the consent. d. Making sure the client signed a consent regardless if she knows what surgery she is having or not. e. Witnessing the signature. 9. Pre-operative instruction that is appropriate for all patients includes. (select all that apply) a. Techniques of deep breathing and coughing b. Descriptions of the plan surgical procedure. c. Physical procedures or preparation required before surgery. d. Withholding of all oral fluids or food after midnight on the day of surgery. 10. The nurse facilitates student clinical experiences in the surgical suite. What action, if performed by a student, would require the nurse to intervene? a. The student wears a mask in the semi restricted area. b. The student has hair covered and a semi restricted area. c. The student wear street clothes in the semi restricted area. d. The student wear surgical scrubs and a semi restricted area. 11. Hey 78-year-old female patient is transferred into the post anesthesia care unit from the operating room and you see and you are assigned to this patient. What initial assessment Will you, as a registered nurse assigned, focus on? a.Airway, breathing, and circulation. b. ntake, output, and intravenous access. c.Abdominal sounds, oxygen setting, and level of consciousness. d. Pulse oximeter, people response, and deep tendon reflex. 12. A 34-year-old patient is in a post anesthesia care unit and you are the nurse taking care of the patient. Patient was placed under general anesthesia during the surgery. Patient started going in and out of sleep. When awake, patient would ask for something to drink and complain of dry mouth. Which of the following actions would you take to prevent aspiration? a. Place a bedside humidifier. b. Suction the nasopharynx to see if there’s any drainage. c. Perform chest physiotherapy percussion. d. Elevate the head of the bed and make the patient you straw. e. With hold fluids until the client demonstrates a gag reflex. 13. The patient is in a post anesthesia care unit and starting to wake up you are assigned to the patient. You will know that this patient was given and understood the post operative teaching prior to the surgery when she makes the following statement. a. I will use an incentive spirometer when I can get out of bed. b. I will deep breathe and cough every four hours. c. I will ask for pain medication after I do my exercises. WEEK 1-MEDSURGE EXAM LECTURE NOTES d. I will splint my incision with a pillow when I cough or turn my body. 14. A patient just had surgery and was prescribed multimodal therapy, which includes acetaminophen, nonsteroidal anti-inflammatory drugs, as needed opiates, and non- pharmacological pain management. The client continuously asked for the PRN opioids, and you are in charge of caring for the patient and suspects that the client might be abusing the use of opioids. Which of the following actions by the nurse is the best? a. Keep on giving us you meant every four hours to see if it works. b. Tell the patient that I hope yours is very addictive and his only for moderate to severe pain. c. Call the healthcare provider and tell him about your suspicion. d. Give the pain medication as ordered because the highest priority is to keep the patient comfortable and drug abuse has not been validated. 15. You are a registered nurse, and are taking care of a patient who came out of a surgery room with a Jackson Pratt. Within one hour of taking care of the patient, you notice that the Jackson- Pratt is for. What immediate action is best? a. Empty the Jackson-Pratt and record the total. b. Call the OR nurse to verify if she emptied the Jackson-Pratt before the patient was transferred to the PACU. c. Look at the site if something is wrong with the Jackson-Pratt. d. Call the surgeon immediately to notify him/her of your findings and empty the Jackson- Pratt and record the total.