Exam 1 Test Blueprint
Initial Post op assessment care: Perioperative PowerPoint, slide 50
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Retention-What would the nurse do first if the patient hasn’t voided in 9 hours post op? Least
invasive to most invasive? Bladder scan, insert straight cath.
Roles of an unlicensed assistive personnel: Perioperative powerpoint slide 47
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What can the Unlicensed Healthcare Worker assist with?
Reinforce teaching, take vital signs, assist with meals
Safety considerations in regard to opiates and benzodiazepines Perioperative slide 25
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Benzodiazepines, sometimes called "benzos", are a class of psychoactive drugs. act as a sedative
– slowing down the body's functions – and are used for both sleeping problems and anxiety. They
work by increasing the effect of a brain chemical called GABA
Benzodiazepines include: lorazepam, alprazolam, diazepam, clonazepam
Side effects of benzos: drowsiness, memory problems, slurred speech, confusion, unsteadiness
and may fall.
The short-term use of these medications is usually safe and effective, but long-term use can lead
to tolerance, dependence, and other adverse effects.
When giving opioids: monitor decreased respirations. Opioids may decrease the patient’s cough
reflex. It is important to have the patient turn, cough, and deep breath regularly to prevent
atelectasis. Give opioid drug at least 30-60 minutes prior to activities or painful procedures.
Malignant Hyperthermia: Perioperative power point, slide 39.
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Malignant hyperthermia: is a rare metabolic disorder, hyperthermia with rigidity of skeletal
muscles. Autosomal dominant trait.
Inherited hyper-metabolism of skeletal muscle resulting in altered control of intracellular calcium
Often occurs with exposure to succinylcholine, especially in conjunction with inhalation agents
Usually occurs under general anesthesia but may also occur in recovery
Signs: Tachycardia, Tachypnea, Hypercarbia, Ventricular dysrhythmias, hyperkalemia,
Rise in body temperature NOT an early sign
If not treated: can cause rhabdomyolysis, can result in cardiac arrest, organ failure and death
Dantrolene for reversal
Body temp of 105 or greater
Be aware of previous family history of Malignant Hyperthermia report to doctors
Normal lab values for CBC: Perioperative powerpoint slide 12
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RBC male: 4.7 -6.1 million
RBC female: 4.2 – 5.4 million
hemoglobin: oxygen-carrying protein
hematocrit: percentage of red blood cells in your blood
Hemoglobin Male: 13-18 g/dl
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Hemoglobin Female: 12-16 g/dl
Hematocrit Hct males: 41-53%
Hematocrit Hct female: 36- 46%
WBC : 5000 – 10000
SCDs-what are they, what do they do: post ope powerpoint
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Intermittent sequential compression stockings (SCDs): provide compression for blood return to
the heart.
Are post op to hopefully prevent blood clots
Vital sign trends-when do you worry when do you continue to monitor: post op powerpont
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Assess vital signs frequently and per hospital policy
Vital signs and trends: a small drop in blood pressure is normal. Know the trends of your patient
Results of intraoperative laboratory tests
DVT signs and symptoms and prevention: post op powepotn
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A big sign is when your calf is warm swollen and painful, there is redness, asymmetrical
enlargement of leg, leg spasms and cramping, abdominal pain – this is an emergency
To prevent it, client needs to be up and ambulating as soon as possible, if possible. If not, he is at
risk of developing a clot. Needs to move legs, wear SCDs, take blood thinners.
Can also develop syncope, electrolyte imbalances, hypokalemia causes cardiac dysrhythmias,
acid base imbalances, fluid overload and fluid deficit.
Albumin-what is it, what does it indicate?: Slide 12 on Perioperative
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Albumin (is a protein made by your liver. Albumin helps keep fluid in your bloodstream so it
doesn't leak into other tissues. It also carries various substances throughout your body, including
hormones, vitamins, and enzymes. Low albumin levels can indicate a problem with your liver or
kidneys) If you have a lower albumin level, you may have malnutrition, problems with wound
healing, infection, thyroid disease, kidney disease
Normal ranges 3.5 to 5
ooooooPost op considerations urinary retention, ineffective airway clearance
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Retention-What would the nurse do first if the patient hasn’t voided in 9 hours post op? Least
invasive to most invasive? Bladder scan, insert straight cath….
Oliguria: urine less than 400 ml in adults
Catheter-associated urinary tract infection (CAUTI)
Interventions: Monitor urine output, Adequate hydration, Remove urinary catheter when no
longer indicated, Normal positioning for elimination and Bladder scan/straight catheter per order
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S&S of atelectasis
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Found on COPD and asthma patients.
Signs and symptoms include trouble breathing, coughing, chest pain, increased heart rate , skin
and lips turning blue. Cyanosis, tachycardia
Symptoms: difficulty breathing, wheezing, cough
S&S of infection
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Fever, chills and sweats, swollen lymph nodes, pain, exhaustion, headache, swelling
Surgical asepsis rules
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Sterile Field: center of sterile field is site of surgical incision
what goes in the sterile field: Only sterilized items in sterile field
Personal protective equipment: Protective equipment, Face shields, caps, gloves, aprons, and
eyewear
Safety considerations: Surgical time-out, confirm name, BD, surgical procedure and site, and
consent
NPO education 00000
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Nothing by mouth
For dehydrated patients
NPO status: Surgery delay may also lead to dehydration. Patients with or at risk for dehydration
may require additional fluids and electrolytes before surgery
Least invasive to most invasive post op respiratory care: slide 45
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EG sit patient up, teach coughing, deep breathing, incentive spirometry(maximum sustained
inspiration). Change patient position every one to two hours. Mobilize early as able, manage
pain, maintain adequate hydration.
Signs and symptoms of hypoxemia: Perioperative slide 44
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Early signs and symptoms of hypoxemia include agitation and confusion
Hypoxemia: below normal levels of oxygen in the blood
Signs and symptoms: headache, shortness of breath, sweating, palpitations, slow heart rate,
cough, wheezing.
00000Therapeutic communication in regards to post op/pre op care: Perioperative slide 40
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Communication is key: Post anesthesia care unit and then later, communicate about safety
discharge or good communication to a hospital unit
Listen to patient
Use signs, give recognition
Seek clarification, be silent.
Post op wound care-what’s normal? What’s abnormal? What should drainage look like? How
much is normal or abnormal? Slide 51
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Assess the wound: note drainage color, consistency, and amount. Normal drainage should be
30ml per hour
A fresh wound should drain more than one that is healing properly. If you've had surgery,
a little serous or sanguineous drainage from the incision is normal.
Abnormal drainages:
Sanguineous-Deeper wounds involving thicker layers of tissue are more likely to produce
sanguineous drainage, or thicker red blood.
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Hemorrhagic Hemorrhage occurs if there’s been damage to an artery or vein.
Purulent milky texture and is gray, yellow, or green odor as well
Seropurulent
Normal types of drainage:
Serosanguinous drainage: is thin, like water. It usually has a light red or pink tinge,
though it may look clear in some cases. Its appearance depends on how much clotted red
blood is mixed with serum.
Serous drainage: is thin and clear, it’s serum. This is typical when the wound is healing,
but the inflammation around the injury is still high.
Different types of pain-acute vs chronic
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Pain is defined as an unpleasant sensory and emotional experience associated with actual or
potential tissue damage
Acute pain: Commonly associated with a specific injury (postoperative pain, labor pain, pain
from infection) Usually decreases as healing occurs. Can last from seconds to 3 months (by
definition). It can invoke the stress response: increasing metabolic rate, cardiac output
Chronic pain: Constant or intermittent pain that persists beyond expected healing time.
Seldom can be attributed to specific cause or injury Lasts for longer than 3 month. Chronic pain
can be disabling and lead to anxiety and depression. Suppression of the immune system: can
cause depression and disability.
Opiates side effects and safety considerations
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Opioids are administered oral, IV, subcutaneous, intraspinal, intranasal
Opioids must be given frequently enough and in large enough doses to be effective
Opioids given orally have been found to provide a more consistent serum level than those given
IM
Respiratory depression and sedation, Nausea and vomiting, Constipation and pruritis: itching are
common side effects with the intake of opioids
Opioid agonists are found to be more responsive to nociceptive pain vs neuropathic pain. For
neuropathic pain, antidepressants and anti-seizure medications are recommended.
Start low go slow- tolerance to the respiratory depressant effects increases if the dose is increased
slowly. Constipation ~ increase intake of fluid and fiber
Drowsiness, confusion, nausea, constipation, slow breathing
Considerations about opioids
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Opioids metabolized in the liver and get excreted by the kidneys
Metabolism and excretion of opioids are impaired in patients with liver and kidney dysfunction,
increasing the risk of cumulative or toxic effects
Untreated hypothyroidism may be more susceptible to the analgesic and side effects
Hyperthyroidism may require larger doses for pain relief
Elderly patients may be more susceptible to the depressant effects
The first dose of opioids should be monitor.
Addiction vs tolerance
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Addiction: is a behavior pattern of substance use characterized by a compulsion to take the
substance, primarily to experience its psychic effects. Many do not become addicted, they
become tolerant to opioids. Some people have fear of becoming addicted, causing inadequate
treatment.
Tolerance: The need for increasing doses of opioids to achieve the same therapeutic effect.
Develops in almost all patients who are taking opioids for an extended period.
COPD patient care (diet needs, o2 therapy needs, safety considerations, physical signs and
symptoms upon assessment)
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Diet needs: has to be high in protein and calories
O2 therapy needs: aim for an SaO2 of 88- 92%. The aim of controlled oxygen therapy is to raise.
the PaO2 without worsening the acidosis.
Oxygne therapy helps prevent right sided heart failure.
O2 therapy is used to: Keep O2 saturation > 90% during rest, sleep, and exertion
Long-term O2 therapy improves: Survival, Exercise capacity, Cognitive performance and Sleep in
hypoxemic patients
Physical examination findings:
Prolonged expiratory phase
Wheezes
Decreased breath sounds
↑ Anterior-posterior diameter (barrel chest)
Tripod position
Pursed lip breathing-pursed lip breathing assists with carbon dioxide elimination
Usually underweight
Pursed lip breathing-what is it? why do we teach it?
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Pursed lip breathing: the purpose is to prolong exhalation, which prevents bronchiolar collapse
and air trapping. It helps to slow respiratory rate and easy to learn. Gives pt more control over
their breathing. To teach, have pt breath in slowly and deeply through nose, then blow out
through pursed lips, like your whistling. We want exhalation to be 3 times as long as inhalation.
Practice 8-10 repetitions 3-4 times a day
Pursed lip breathing-pursed lip breathing assists with carbon dioxide elimination
If patient becomes anxious because of dyspnea, teach pursed lip breathing
Acute Sinusitis – slide 12 of Oxygenation 1 and page 485 in book
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“acute sinustitis typically begins within 1 week of an upper respiratory tract infection and lasts
less than 4 weeks.”
Plan of care for COPD patients
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Relieve symptoms, and prevent complications
Prevention of disease progression
Ability to perform ADLs
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Relief from symptoms
No complications related to COPD
Knowledge and ability to implement long-term regimen
Overall improved quality of life
Return to baseline respiratory function
Demonstrate an effective rate, rhythm, and depth of respirations
Experience clear breath sounds
No infection
Epistaxis-treatment, safety considerations SLIDE 7 Respiratory 1
Epistaxis: bleeding from the nose
Treatments and Care:
Lean head forward, and pressure if not stop within 15 minutes, seek help
Nasal tampon
Epinephrine
Packing for posterior bleeds, balloon- only for 2-3 days
Monitor LOC, heart rate & rhythm, RR, O2 sat, issues with breathing or swallowing-requires immediate
intervention by RN if 02 sat is dropping
Pain medicine and antibiotics needed
Teach no vigorous nose blowing, no NSAIDs, no lifting or straining for 4-6 weeks
Allergic rhinitis-triggers and treatment
Allergic Rhinitis
Episodic, intermittent, persistent
Manifestations:
Sneezing
Watery eyes
Itchy eyes and nose
Altered sense of smell
Thin, watery nasal d/c
Nasal congestion
Pale, boggy turbinate
headache
Teach to avoid triggers-First thing and important
Drug therapy to reduce inflammation
• Nasal corticosteroids
• H-antihistamines-first generation (diphenhydramine) second generation- cetirizine (Zyrtec)
loratadine (Claritin) fexofenadine (allegra)
• Decongestants-pseudophedrine (Sudafed) promotes vasoconstriction, reduces nasal congestion
• Leukotriene receptor antagonists
(Review the Medication table on pg. 479)
Rhinoplasty post op care positioning
P 478 in book (CH 26). After surgery nasal packing removed 1-2 days following surgery. Post op
elevation of the head can help minimize swelling along with cold application. Activity aimed at
preventing bleeding
Chest tube-care and complications, PowerPoint 2 respirations slide 5
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Position patient: arm raised up on affected side 30 – 60 degrees
Clean area with antiseptic solution
Local anesthetic administered, small incision
Once inserted, sutures to keep in place, cover with occlusive dressing
Connect to a pleural drainage system
Care of tube: keep all tubing free of kinks and occlusions, keep tubing below the level of patient’s
chest. Do not attach to movable things, put in immobile area. Check tube for bubbles, means air
leakage.
Complications of chest tube: pain, vascular injury, improper positioning of the tube, inadvertent
tube removal, postremoval complications, longer hospital stays, empyema and pneumonia
Chest tube tidaling
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Tidaling: in concer with respiration, reflects changes in pressure. Disappears as lung re-expands.
Flail chest signs and symptoms
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Situation in which a portion of the rib cage is separated from the rest of the chest wall, usually
due to a severe blunt trauma, such as a serious fall or a car accident.
Signs and symptoms:
Bruising, discoloration, or swelling in the area of the broken bones.
Sharp severe chest pain
Difficulty inhaling or getting a full breath
Lung Cancer education in regards to smoking Slide 29 Oxygenation 1
“Quiting reduces risk”
Pneumothorax signs and symptoms
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Pneumothorax is caused by air entering the pleural cavity. Positive pressure causes lung to
collapse.
Signs and symptoms include: sharp stabbing chest pain that worsens when you breath. Shortness
of breath, cyanosis, fatigue, dry skin, rapid breathing, and heartbeat
Clinical manifestations: mild tachycardia and dyspnea, severe respiratory distress, absent breath
sounds over affected are, evident on x-rays
Treatment for pneumothorax: thoracentesis, which is pulling fluid out. As that fluid gets pulled
out it can cause a new pneumothorax
Pulmonary Embolism-signs and symptoms, initial nursing interventions, tests. Powerpoint 2 of
respirations 14
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Pulmonary embolism: blockage of one or more pulmonary arteries by thrombus, fat, air embolus
or tumor tissue. Affects lower lobes. DVT most common.
What causes PE: immobility, surgery, obesity, smoking, atrial fibrillation, heart failure, clotting
disorders, pregnancy/delivery
Signs and symptoms: Dyspnea, tachypnea, cough, feeling impending dome, chest pain,
hemoptysis, crackles, wheezing, fever, tachycardia, syncope.
Initial nursing interventions: Sit them up high fowlers position, get vitals, place on O2. Oxygen,
pulmonary hygiene, semi-fowlers position, frequent vitals sign assessments, IV access, monitor
lab results, emotional support, patient teaching to prevent DVT
Complications: pulmonary infarction and alveolar necrosis and hemorrhage.
Test: a spiral helical CT scan is the most common test to diagnose Pulmonary embolism. CT
pulmonary angiography. V/Q scan
Blood test: D-dimer, troponin levels, ABGs
Thoracentesis- what is it? Risks? Benefits?
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Treatment for pneumothorax: thoracentesis, which is pulling fluid out. As that fluid gets pulled
out it can cause a new pneumothorax
Benefits: relieve pressure from fluid on the lungs, treating symptoms such as pain and shortness
of breath.
Needle inserted into intercostal space. Drain no more than 1200mL at one time. The Nurse’s role
Cor Pulmonale-signs and symptoms
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Enlargement of right ventricle caused by a respiratory disorder.
Manifestations: Dyspnea, tachypnea, cough, fatigue, JVD, chronic hypoxemia that leads to
polycythemia, peripheral edema, weight gain.
Linked to pulmonary hypertension, heart failure and chronic COPD.
Medications: Give O2 slowly, vasodilators, calcium channel blockers, anticoagulants
Asthma-medications and supplies needed for care, emergent medications, side effects of
medications used to treat Asthma.
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Medications include: bronchodilators, anticholinergics, anti-inflammatory drugs: corticosteroids,
monoclonal antibody, and leukotriene modifiers.
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Bronchodilators: for long acting asthma (Beta Agonists Symbicort and salmeterol), used with
corticosteroids. They achieve and maintain control of persistent asthma.
Anticholinergic: for long acting asthma. Theophylline ( not as common due to toxicity, must
monitor blood levels keep 10-20 and avoid caffeine.
Short acting beta agonist: Albuteral ( not for daily use) if pt is using more than 2 x a week,
Asthma is not under control, need to revisit asthma action plan KNOW THIS FOR TEST . Normal
sig of albuterol is being jittery.
Anticholinergic Short Acting-Iprotropium-used when the pt can’t tolerate the Beta Agonist
(because beta agonist increases heart rate, jitteriness)
Anti-inflammatory asthma drugs
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Corticosteroids ~ decrease inflammation, suppress the immune system can take them inhaled,
po/IV. Long term use, not for acute attack. Meds: Fluticasone, Budesonide, Beclomethasone,
prednisone, prednisolone, triamcinolone, …side effect thrush-use with a spacer, wash mouth
out after use. Long term usage can result in osteoporosis and cataracts
Leukotriene modifiers ~ montelukast sodium (Singular), zafirlukast (Accolage) and zileuton
(Zyflo) (These medications-block leukotriene, what does leukotriene do? it makes smooth
muscle constrict and increases mucous production)
Monoclonal antibody to IgE ~ Omalizumab, Mepolizumab, Benralizumab block IgE-used in
patiets with poorly controlled asthma, not for quick relief, don’t give live vaccines if patient is on
this medication.
Tracheostomy-care and potential complications
Advantages over endotracheal tube:
Easier to keep clean
Better oral and bronchial hygiene
Patient comfort increased
Less risk of long-term damage to vocal cords
Cleansing inner cannula
Gather equipment, position patient, don PPE, set up equipment, Don sterile gloves
Unlock and remove inner cannula, place in sterile saline, cleanse, rinse, reinsert
Precautions:
Replacement tube at bedside
Do not change ties for 24 hours
Physician performs first tube change
Cuffed vs uncuffed, typically we use cuff in acute care mechanical ventilation or pt as
risk for aspiration. Keeps the tracheostomy tube in place.
Uncuffed is for long term care, allows the patient to talk when possible and eat
Assess the site every shift, clean the inner cannula every shift, change trach ties after the
first 24 hours, using a two person technique. One hold the trach steady and the other
changes the ties/tape
Safety considerations: always have a trach of same size and 1 smaller at the beside.
Asthma Attack-signs and symptoms
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Signs and symptoms include: Recurrent episodes of wheezing, breathlessness, and tight chest.
May be abrupt or gradual, lasts minutes to hours.
Common manifestations: cough, shortness of breath (dyspnea), wheezing, chest tightness,
variable airflow obstruction
ASTHMA ACTION PLAN NEEDED ON ALL PATIENTS SO THEY CAN TRACK
THEIR PROGRESS AS WELL AS SIGNS AND SYTMPOMS OF AN IMPENDING
ASTHMA ATTACK!!
Peak expiratory flow rate (PEFR)-test of lung function, can predict an asthma attack or monitor
the severity of the disease
Pneumonia-initial signs and symptoms related to hypoxemia – Slide 19 Oxygen 1
Vital Signs including oximetry
Fever, Restlessness or lethargy, Splinting affected area, Tachypnea, Asymmetric chest
movements,Use of accessory muscles , Crackles, Friction rub, Dullness on percussion, Increased tactile
fremitus Sputum amount and color, Tachycardia, Changes in mental status
Bronchoscopy-risks
IAW slide 5 of Oxygen 1 refer to P 472 of text “Keep patient NPO until gag reflex returns. Monitor
fror recovery from sedation. Blood-tinged mucus is not abnormal. If biopsy was done, monitor for
hemorrhage and pneumothorax.
A bronchoscopy may be done to diagnose and treat lung problems such as: Tumors or
bronchial cancer. Airway blockage (obstruction) Narrowed areas in airways (strictures)
Flu vaccine, risks, who should receive it?
P 485 “contraindications are patients wwith a history of severe allergic reactions to flu vaccines. Patients
with anaphylactic hypersensitivity to eggs should discuss the vaccine with their HCP as alternatives for
vaccinating patints with egg allergies are now available.”
Pharyngitis treatment
Viral (90%), bacterial, fungal
Group A beta-hemolytic streptococci- 5-10% can turn to rheumatic
Manifestations:
Throat pain
Red, swollen posterior oropharynx
If bacterial: Fever, Lymph node enlargement, Exudate, No cough
Nursing Care: Infection control, Symptom relief, Prevention of complications, Warm salt water gargle,
popsicles, hard candy, lozenges
If bacterial, penicillin 1st line ~ ~ Contagious through 2 days of ABT(allogeneic blood transfusion)
Typically on abx for 10 day
Complication: rheumatic fever-from streptococcus pyogenes, which is also called group A
streptococcus
Pneumonia initial nursing interventions Slide 20-21 alteration in oxygenation 1
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Prevent dehydration,
Evaluations:
Oxygen therapy, suctioning, coughing, deep breathing, adequate hydration , ventilation
Kahoot questions
Pt with COPD exacerbation is experiencing anxiety and air flow difficulty. What is the best initial
action by the RN?
High fowlers position, with elbows resting on bedside table
(PACU) a pts vs: bp 116/72, pulse 74 beats/min, respirations 12 breaths/min, and SpO2 91%First
nursing action?
Encourage the patient to take breaths
The client is receiving post operative analgesia through a (PCA) pump. What is the most important
nursing assessment?
Respiratory depression
Nurse is caring for a client with bone cancer. The client asks why do I keep having to take longer
doses of pain meds?
Over time you become more tolerant of the drug
A clint who is receiving oxygen therapy for pneumonia may be becoming hypoxic, what should the
RN assess first?
Confusion
A nurse is performing trach care using surgical asepsis. Which practice violates surgical asepsis?
Holding sterile objects below the waist
RN assesses a patient on 2nd postop day after abdominal surgery to repair perforated ulcer. What’s
most important for the RN to report
300 ml of sanguineous fluid
When caring for a client experiencing acute pain, which intervention is appropriate for the nurse to
delegate to UAP?
Gibe something to apply to the site of pain