PREOPERATIVE NURSING ● Role of the nurse: Assessing and teaching data ○ Assess patient to make sure they are healthy enough to go into surgery ■ What should you assess the patient for? Risk factors that could put the patient at a greater risk for complications. ○ Teach patient what they should expect or see when they wake up ■ Lines, drains, splints, etc. ■ Things to do to prevent complications after surgery. ■ Pain Assessment: ● Risk factors: ● Anxiety – always ask about anxiety ● Allergies: ○ Latex: food: avocado, bananas, chestnuts, eggs, kiwi, potatoes, peaches, Hx of hay fever. Hx of reactions that suggest a higher risk of having allergies to latex, food, etc. ○ A patient with a hx of any allergic reactions has a greater potential for hypersensitivity reactions to drugs given during anesthesia. ● Iodine: shellfish allergy; iodine is in IV contrast ● Medications: Assess for herbal supplements, dietary, recreational, otc, etc. ● Patient’s baseline: important to know how they are before they go into surgical procedure. ○ Vital signs ○ Blood sugar ○ Lung sounds ● PMH: (past medical history) ○ Health problems ○ Any issues w/ prior surgeries ○ Personal or family issues w/ anesthesia Risk factors for surgery: ● Increased age: older age = more complications they have . ● Health status/comorbidities ○ DM: Delayed wound healing could cause infections ■ Stress on the body = increased blood sugar ○ HTN: more at risk for a stroke ■ If risk is very high, NO surgery will happen. ○ A-Fib: Which medications are they on? blood thinners, they have irregular heart beats. ■ Notify doctor if they took their blood thinner, because they will be at risk for bleeding out. Patient should be off blood thinner 72 hours to week prior to surgery ○ COPD: Not getting enough oxygen. Poor ventilation/ lung expansion/ oxygenation. ○ Asthma: @ risk for anaphylactic reaction and infections (UTIs) ○ Hx of smoking/Smoking: Causes respiratory problems. Lungs don’t fully expand; you retain secretions which cause other problems. ○ CKD: May cause fluid volume overload due to isotonic solutions administered. ■ May not be able to filter anesthesia as quickly → delays recovery ○ Anxiety: Fear of death, fear of pain and discomfort. ■ If pt states im going to die → do not send them to surgery. ■ Anxiety can be decreased by giving information about what to expect. Teaching, address concerns, if they want the procedure explained again call the surgeon to explain the procedure. ○ Obesity: Increased dosage of anesthetics → takes longer to clear out of the body → delays recovery. ■ Obese patients metabolize anesthesia differently, they hold onto it and recovery takes longer. ● Medications: ○ Recreational drugs - stress that substance use may affect the type and amount of anesthesia the pt will need. ○ Blood thinners - Causes an increased risk for excessive bleeding. Patients may have a hard time clotting. ■ Types: Coumadin, ASA, Plavix, Aleve, ibuprofen, Aspirin, warfarin. Must be off them from 72 hours to 1 week prior to surgery. ○ Insulin: need to know if the patient took insulin prior to surgery ○ Steroids : ■ DO NOT ABRUPTLY STOP STEROID. They are tapered. ■ Work in the adrenals, if abruptly stopped the kidneys can shut down ■ What do steroids do to blood sugar? Increase it. ● Baseline: to compare results to intraop and post op ○ GI: motility sounds ○ VS (BP,O2, T, RR, HR): What are pt's norms? VS ARE THE KEY TO EVERYTHING. ■ Which 2 are most important: BP and O2 ○ Lung sounds:we want to know how they are before they go into the procedure. ○ Blood sugar:we want to know how they are before they go into the procedure. ○ Physical assessment ○ Labs Labs - NEED TO KNOW ALL ● WBC: (4.5 - 10) ○ Indicates infection. ■ (at more risk for infection/ immunocompromised if lower than 4.5); (if too high they have an infection). ● H/H: (9/25) ○ Indicates low fluid volume in body. ■ Hgb – anemic/circulating blood volume, HCT – anemic/circulating blood volume. ● Plts -> (150 - 400) ○ Assesses if blood will clot fast enough or not/ Indicates risk for bleeding. ■ (plt level too high = risk for clots) (plt levels too low= risk for bleeding) ● BUN/ Creatinine (8-25; 0.6 - 1.3) ○ Assesses kidney function ● Electrolytes: ○ K: 3.5-5.0 ○ Na: (135-145) ○ Cl: (98-107) ● PT: (9.6 - 11.8) - What does this lab assess? At risk for bleeding ● PTT: (20-36) - What does this lab assess? At risk for bleeding ● INR: (2-3 if on coumadin) - What does this lab assess? At risk for bleeding Pt, PTT, INR – If high, they are at risk for bleeding. If low,they are at risks for clots. Opposite of platelets. Low PT and PTT → means blood will clot faster; you will have more clots If PT is 40 > your blood will clot slowly, like in 40 seconds. Patient education: ● Expectations: PCA pump, tubes, dsrg, catheters, NGT drains, sutures ○ Tell patient where they will be. ○ Start teaching about post op exercises ○ Teach them about pain, sutures, etc. ● Pain medication: CNS depressant = respiratory depression - Monitor O2 saturations ● Post-op exercises: - Ambulation, lovenox, SCD’s, compression socks, IS Prevention of complications: ● Atelectasis: IS, TCDB ● DVT/PE: leg exercises, SCDs, TED hose ● Mobility: turning (prevent skin breakdown), walking (incr. GI motility) ○ Better outcomes and faster recovery, reduce anxiety and decrease post – op complications. Pre-op checklist: Informed consent ● Surgeon: Responsible for explaining the procedure, complications, and teaching risk and benefits ● ● Nurse is responsible for obtaining signature ○ Make sure patient understands what the doctor told them Contraindications to patient signing informed consent: - On sedation meds - Deficient knowledge - minor Pre-op checklist: Making sure the patient is safe enough to go to the operating room. Identify risk factors. - Id bracelet - Allergy band - Baseline VS - Labs - H&P - Signed informed consent - Blood type and crossmatch - NPO status - Valuables, dentures, glasses, contacts INTRAOPERATIVE NURSING Role of nurse: ● Safety and comfort of patient: ○ Proper padding: (elbows, heels, bony prominences) - take in account of how long the procedure will be. ■ They could have skin breakdown if adequate/proper padding is not supplied. ○ Proper alignment and positioning of the patient ○ Strapped in safely: to prevent nerve damage. We don’t want patients to fall off the operative table during surgery. Time out: The most important thing we do in surgery ● The final time to make sure everything is correct ● You know everything you can about the patient’s health - last time to catch an error ● MD makes site in pre-op phase, but we (the nurse) need to ensure the right site is marked prior to procedure ● Informed consent should be reviewed, H&P, allergies need to be there ● Done prior to procedure and right before beginning the procedure Anesthesia: ● Stage 1: DROWSY to UNCONSCIOUS ○ Difficult to arouse ○ Inhalation agents (I.e. succinylcholine) ● Stage 2: Known as excitement phase - think of muscle excitement ○ Muscles get tense ○ ○ ○ Shallow to irregular breathing: Getting ready to begin the intubation process Pt may vomit so ... ■ Place them on lateral side so they do not choke on their vomit Ketamine – you must have a quiet environment for this agent to be administered, if not the pt can have horrible hallucinations. ● Stage 3 –reflexes lost - paralysis ○ Muscles loosen ○ breathing regular again - b/c patient is intubated ○ usually dlt adjuncts ○ vitals are depressed ● Stage 4: all reflexes lost - complete respiratory depression. Tubed and vented. - Completely ventilated - dependent on us - neuromuscular blockers Classifications of Anesthesia: ● General: inhalation; of choice for surgeries of significant duration ● Adjuncts to general: ○ Opioids- sedation and analgesia; pain management; resp depression ○ Benzodiazepines- premedication for amnesia, induction of anesthesia, monitored anesthesia care ○ Neuromuscular agents- facilitate endotracheal intubation, relaxation of skeletal muscles ● Epidural: manage pain up to 72 hours post op; injected; have emergency equipment available ● Local and regional: rapid recovery, little residual hangover, possible discomfort, hypotension, seizures Intraoperative Complications: ● Hypothermia: What can we do for the pt? assess temp, warming blankets and warm fluids as needed ● Hypoxia: we would look for their 02 sats – constantly ● Anaphylaxis: ○ S/S: hypotension (1st signs), tachycardia(1st signs), elevated respiration rate(1st signs), Bronchospasms, wheezing, pulmonary edema, crackles. ○ Typically found on the end of inspiration and beginning of expiration. ○ Manifestation may be masked by anesthesia; rapid intervention ● Aspiration: Put patient in lateral position ● Fluid and electrolyte imbalances: - Caused by getting fluid too quickly (fluid pouring). - Know what fluid they are getting and what it does to the body. ● Environmental: complications that can happen in the environment: Fire → b/c inhalation agents (oxygen) are HIGHLY FLAMMABLE Malignant hyperthermia: Rare metabolic disorder, Usually while under general anesthesia ❏ Often occurs with exposure to succinylcholine ❏ They can change the inhalation agent if it is genetic. ❏ Autosomal dominant trait ❏ MH is genetic in nature and has a genetic component. ❏ Can result in cardiac arrest and death - Can cause organ failure, it is deadly. ❏ Rigidity of skeletal muscles: Can’t regulate calcium ● Causes: - inhalation agents; Happens from anesthesia agent -> succinylcholine - Genetics; Has a genetic component- why we ask if family/patient has had reaction to anesthesia ● S/S: Tachycardia (> 150) (earliest sign), tachypnea (earliest sign), increased CO2, rigid muscles, fever (latest sign) - Early sign is tachycardia and tachypnea increased temp is a late sign. ● Tx: Anything that cools the pt: lower thermostat, ice, cooling blanket. ○ Antidote is Dantrolene, causes the muscles to relax. ○ Stop surgery, stop agent responsible for hyperthermia, give 100% O2 ○ Lidocaine is used to relax the heart down to make the tachycardia go away. POSTOPERATIVE NURSING Entry of client into recovery until discharge home or onto unit. PACU - immediately after surgery ● Role: ○ Assessment of complications ■ Important to maintain vitals and maintain an open airway ○ Prevent complications. ○ Ask the OR nurse how the patient tolerated the surgery. ■ Bleeding, how was their BP? ■ What anesthesia was used? ○ What can you do for the pt in this phase? (EVERY 5 min and when they get to the floor it is every 15 min) ■ VS, lung sounds, give patient O2, pain meds, raise head of bed to 30 degrees, Assessing complications ● Airway: Assess if artificial airway patent. Interventions: raise HOB, suction ● Breathing: Assess RR, quality, assess SaO. Intervention: give O2, TCDB, IS, Splinting ● Circulation: Assess: ECG, BP, pulse, cap refill, skin color (pallor), temp (cool). Interventions: Ambulate, SCDs, TEDs, anticoags ● Neuro: Assess: LOC/ neuro state. Interventions: Reorient, explain procedures ● Gi/Gu: Assess: for N/V, I/Os, wt, fluid volume overload (How much fluids did the pt receive?), must have no less than 30ml output every hour. Interventions: ambulate, ● S/S(surgical site): assess for s/s of infection (WBCs, drainage color, etc). Interventions: sterile technique, wash hands, dressing, antibiotics. CKD (Chronic kidney patients) Patients Post-op period: ● What do you need to ask the OR nurse regarding a CKD patient? ○ Ask OR nurse how much fluid pt had? What type of fluid? ● Important assessments ○ I&O ○ Listen to lung sounds - crackles - signs of fluid in lungs Day 1:Atelectasis: collapse of the alveoli ● Most common complication that occurs 24 hours after surgery ● Can cause pneumonia if fluid just sits in the lungs ● S/S: crackles, decreased breath sounds, incr RR, restlessness ● What can we do to prevent this? IS, TCDB, ambulation, Huff cough, splinting, more fluids in order to increase IV fluids. ● Treatment:Oxygen, high fowlers, use pulse ox, IS, turn cough deep breath, ...do interventions. Up to 24 hrs: Hypovolemic shock: aka - bleeding ● Most common complication 0-24 hrs after surgery; within the first day ● Causes: Loss of fluids/ bleeding, dehydration ● S/S: low bp, high HR, high RR ● Interventions if the patient is actively bleeding: 1. Put pressure to the wound 2. Put the patient in trendelenburg position - (gives blood to vital organs) 3. Administer fluid or blood 4. Notify the doctor Day 2: Clot formation or DVT: ● S/S: calf pain, swelling ● Cause: Due to lack of movement ● ● Prevention: SCD, ambulation, blood thinners (Plt level must be greater than 150 for lovenox to be administered) Teach: walking prevents clots Day 3: Infection. ● Occurs day 3 and on... after surgery. Does not happen overnight ● Can be ... ○ atelectasis progressing to pneumonia, UTI, respiratory infection ● S/S: Red, swollen, yellow drainage, fever, tachycardia ● Prevention: Hand washing, antibiotics, wound care, dressing changes, aseptic technique, keep patient clean ● Prevention of UTI: Really good peri care (front to back); Remove catheter or change the catheter/Catheter care; Hydration to get infection out; Urine culture and antibiotics if they have an infection. Day 4: Dehiscence and evisceration: normally from patients who have had GI surgery and are larger in weight. ● Dehiscence: stitches pop ● Evisceration? Organs protrude ● What do you do if this happens? 1. Cover with moist sterile dressing w/ saline→ keeps organs moist/alive and increases circulation. It prevents organs from rotting, if organs are dry they die. - Sterile dressing: prevents infection 2. Position: Low fowler's @ 30 degree angle with knees bent → relieves tension and pressure on the abdomen; prevents further evisceration. 3. Lastly we call the MD . ★ Prevention from these occurring: abdominal binder, (best), can also splint. 5. Pulmonary embolism: Day 2 complication. S/S: chest pain, dyspnea (Early Finding), increased respiratory rate, disoriented, lethargic, restless(Late Finding). - Now we need to know early vs late assessment findings. Know when these complications are most likely to occur… Postop: Pain control: ● Assess anesthesia used and pre op med client received ● If opioid prescribed, assess client every 30 minutes for RR and pain relief; If on PCA, ensure client with PCA understands use ● Try using noninvasive measures to relieve post op pain ● GI: Absent bowel sounds – normal b/c they just got out of anesthesia and it puts their gut to sleep, BUT not good if they are absent after postop day 1. ● Observe the drain and fluid, but NEVER take off the first dressing; Only the surgeon takes off the first dressing on the patient. You just get a new dressing to reinforce. ● Urinary – MUST have at least 30 ml. LECTURE 2: DIABETES MELLITUS Pancreas: ● Function: ○ Influence carbohydrate metabolism ○ Produces insulin and glucagon ○ Protein metabolism INSULIN CARRIES GLUCOSE OUT OF THE VASCULAR PLACE!! Diabetes Mellitus : ● What is Diabetes Mellitus? ○ Chronic disorder of impaired carbohydrate, protein and lipid metabolism caused by a deficiency of insulin resulting in hyperglycemia. ● What does insulin do? ○ Carries glucose out of the vascular space and into the cells. ● No insulin means increased glucose levels, why? ○ Insulin breaks glucose down. No insulin → glucose can’t be broken down causing increased glucose levels. ● When cells starve they begin to break down protein/fat for energy. ○ Because their body can't break down proteins. Proteins are huge molecules, the kidneys work harder and make a lot of urine to try and get rid of protein. ■ Proteins will bust through the kidney filters → pts have blood and protein/ketones in their urine ■ Breakdown of fat=Metabolic ACIDOSIS Diabetes and circulation: ● Maintaining perfusion in diabetes is key!! ○ Issues with perfusion b/c of the fat buildup and scarring of arteries causing them to harden and stiff. ● Due to the poor circulation, diabetics are at higher risk for increased risk for infection b/c poor wound healing. ● Lower extremities are mainly affected Diabetes Pathophysiology: ● Type 1 ● Autoimmune. ● They make NO insulin – These pts only get insulin – no pills ○ Will always need insulin - Insulin dependent diabetes mellitus (IDDM) ● Rapid onset - all of a sudden ● Occurs in childhood or early adulthood. ● Ketoacidosis - usually in DKA state ● Type 2 ○ ○ ○ Pancreas still makes SOME insulin but not enough. ■ Can take pills and insulin b/c the pancreas still makes some insulin Slow onset – insidious Occurs in adulthood ■ Usually not aware that they are diabetic Risk factors: ● Type 1: ○ Genetics ● Type 2: ○ Obesity, family history, older age, unhealthy lifestyle Assessment findings: ● Type 1: relate to volume loss and cellular "starvation". ○ 3Ps – Hallmark clinical manifestations: ■ Polyuria: peeing a lot b/c the kidneys are trying to get rid of the ketones. ● We try to keep pt from going into hypovolemic shock b/c they are peeing too much and not concentrating the urine. They are pouring out dilute urine and making themselves dehydrated. ■ Polyphagia: always hungry ■ Polydipsia: increased thirst ● They are not able to concentrate the urine and their body needs the fluids b/c they are dehydrated. ○ Fatigue and weakness ○ Unexplained weight loss; decreased wt(Because of the fat breakdown) ○ Hot, dry skin; Dry mucous membranes ○ Blurred vision ● Type 2: ○ 2 Ps: Polyuria and polydipsia ○ Fatigue ○ Prolonged wound healing - Poor circulation/perfusion ○ Changes in vision ○ Weight gain or loss ○ Recurrent more frequent infections ■ UTIs, yeast infections ○ Large amounts of ketones, protein and sugar in urine. ○ When the blood sugar is out of control, what are the s/s? ■ 3Ps: Polyphagia, body is looking for energy; polydipsia; polyuria, ■ Patient may be @ risk for hypovolemic shock b/c they can’t concentrate their urine and cannot control their urge to urinate. Diabetes Mellitus Diagnosis tests: ● Fasting blood sugar(FBS) ● ● ● ○ could have diabetes if > 126 - needs to do further testing ○ Cannot eat for period of time (8hrs). ○ Usually 1st test Casual Blood Sugar - fingerstick ○ > 200 and having symptoms (peeing a lot...etc) will do further testing. Glucose Tolerance test: > 200 ○ Give pt glucose drink, wait 2 hours and then test BS ○ If they BS greater than 200 pt probably have diabetes b/c the body was unable to break down the sugar. HgbA1c (AKA: glycosylated Hgb) It tells you the average over 3 month period. ○ Not the 1st test done. Indicates how well the body has been breaking down sugars. ■ 1st time diabetic patients will be high because they haven’t been regulating their blood sugar very well. ○ Measures of whichren 1% of hgb is coated w/ glucose (glycated). Once glycated, a hgb molecule will remain for the remainder of the RBCs lifespan - 120 days. The higher the HgbA1C the higher the blood glucose levels have been over the past 90 days. ○ > 8 is BAD for an established diabetic patient. ■ < 7 is good for established diabetic pt. ■ 5.7 or less is normal. Treatment for Type 1 diabetes: ● Pt will need insulin forever. ● INSULIN Treatment for Type 2 diabetes: - Diet and exercise - 1st interventions then insulin - Insulins - Oral antidiabetics Type 2 Diabetes and diet: ● Diet: ○ Decrease protein and cholesterol: Because diabetics can’t break it down. ● Reduces vascular damage. Will cause less damage to kidneys ○ Increase fiber: Helps with absorption of glucose. ■ If patient is hypoglycemic we give them OJ and Apple juice but apple juice is preferred. Apples are higher in fiber. ○ 55-60% complex carbs: ■ Brown rice, whole wheat, oat, quinoa, bananas, oatmeal, beats, lentils, yams, sweet potatoes ○ 20-30% fats: healthy fats: Avocado, nuts, canola oil, olive/coconut oil, almonds ○ 12-20% protein – chicken, fillet mignon, fish (salmon) ○ Decrease alcohol use:Decrease you do not have to eliminate. ■ Alcohol turns into sugars, and interacts with a lot of diabetic meds. ● Exercise: ○ Need to wait for BS to normalize before they start exercising ○ Exercise the SAME time and routine every day ■ Less fluctuations. ○ Exercise causes bs to go down! ■ Exercise when BS is highest. BS is the highest in the afternoon and is the lowest in the morning. ○ Slowly increase exercise. 20- 30 minutes a day, 3-4x a week. ○ 60 – 80% of your maximum hr. ○ Snack before exercise → apple (more fiber). Pt should eat the snack around 30 min before exercising. ○ Exercising can lower your BS for up to 48 hrs. ○ Aerobic exercises: ■ Swimming, walking, resistance training, using bands, normal body weight exercises ■ We don’t want diabetic pts to do any heavy lifting exercises. Oral antidiabetic medications: TYPE 1 DIABETICS ONLY GET INSULIN ● Sulfonylureas (includes: glipizide, glyburide, glimepride) → Work in pancreas ○ Stimulate pancreas to release insulin ○ PT CANNOT DRINK ALCOHOL, teach pt ○ Will cause weight gain because excess fluid retention ■ Closely monitor HF and CKD b/c they are already at higher risk for fluid overload ○ Give with food to decrease symptoms of n/v. ○ Side effects: N/V, upset stomach, hypoglycemia, weight gain ● ● ● Meglitinides (similar insulin release as sulf.) → work in pancreas ○ Faster acting but shorter duration ○ Take 30 min before meal; DO NOT TAKE IF MEAL WAS SKIPPED ○ Less chance for hypoglycemia with this medication Biguanides → Work in liver ○ Inhibits the way the liver produces glucose ○ First in line treatment for T2D ○ Take with food because this causes GI upset ○ Contraindicated for CHF, liver failure, CKD pts ○ Hard on kidneys; Can be toxic to lungs, liver, kidneys ○ Metformin: MUST BE OFF 48 HOURS BEFORE IF PATIENT IS GIVEN IV CONTRAST ■ Iodine is also hard on the kidneys. Iodine is metabolized in the kidneys and can cause the kidneys to shut down. Thiazolidinedione → works in muscle and fat ○ Can cause liver toxicity ○ ○ ○ Tests: AST, ALT, total bilirubin → to look at the liver enzymes. Side effect = wt gain bc they retain fluids – edema b/c they retain fluids. Caution with CHF pts ● Alpha-glucose inhibitors → works in small intestine/GI tract to speed up and clear out the food faster. ○ Side effect = diarrhea (biggest SE) ○ Causes hypoglycemia when not given with food → give with 1st bite of food. ○ Starch blocker (miglitol) ● Incretin mimetic (Byetta or victoza) NOT INSULIN but given Sub-Q ○ Stimulates insulin release and decreases the secretion of glucose ○ Side effects = N/V, HTN, (Biggest SE, most common) DECREASES gastric emptying( constipation, feeling of fullness), hypoglycemia ○ Increase pts fiber in diet ○ Only for type 2 pts. Any diabetic drugs they are at risk for liver toxicity. Know peak, onset and duration. Peak is most important. - Insulin tips: ● SQ – clear then cloudy (which is which?) ○ Air into cloudy, air into clear, draw up clear, draw up cloudy. ○ CANNOT MIX LONG ACTING INSULINS ● IV – Regular insulin can be given IV - Onset: 30 – 60 min; Peak: 2-4 hr; Duration: 5-8 hr. Complications of Diabetes Mellitus: ● Hypoglycemia: BS level < 70 ● Risk factors: ○ Increased insulin - Giving too much ○ Decreased food intake ○ Increased exercise ○ Alcohol ● S/S: Diaphoretic (Cold and clammy), Sweaty, Shaky, Irritable, hungry, Anxious (late), Confused (late), Dec LOC(late), Tachycardia(late) ● Onset: sudden may lead to insulin shock ● Tx: Conscious and unconscious ○ Conscious: Rule of 15's ■ 15g carb (ex. fruit juice, 5-8 lifesavers, 4-6 oz of regular soda, commercial dextrose products). ■ Best is: 4-6 oz Apple, it has fiber in it. ○ Unconscious - Glucagon (thick syrupy consistency that sits in their mouth) or IV dextrose (50%) [BIG syringe, Hard to push, consistency is very thick] ■ Recheck BS in 15 minutes, if BS < 70 – repeat the process ● Hyperglycemia: > 110 ○ If pt has hyperglycemia > 250, increase risk for infection for more than 2 weeks. ○ S/S: 3Ps (polydipsia, polyuria, polyphagia), blurred vision, nausea, drowsiness, hot and dry ○ Causes/Risk factors: no treatment, infection, changes in eating, insulin administration or exercise regimen, malfunction of insulin pump, stress, illness, skipping meds ○ Treatment: Insulin, medications ● DKA (metabolic acidosis) → Type 1 ○ Glucose BS > 250 ○ Ketonuria - large amounts in urine ○ Low pH <7.3 ○ CO3 <15 ○ Symptoms: N/V, dehydration, Kussmaul’s respirations (hallmark symptom), acetone odor to breath (hallmark symptom), infection, Low LOC, lethargic, not alert and oriented, 3p’s, tachycardia, hypotension, hypokalemia. ■ Kussmaul RR: Hyperventilating state. It is what pt does to compensate for the metabolic acidotic state; Deep, labored breathing, rapid breathing, ● Tx: We are trying to prevent hypovolemic shock b/c they are dehydrated - there is too little fluid. ○ IV fluids: Start with isotonic fluids until blood pressure is stabilized and UO is 30 - 60 ml/hr. Must be given fluids or else they will go into circulatory collapse. ■ Isotonic NS(0.9 Sodium chloride). ○ IV regular insulin until BS 200-300. Slow infusion of regular insulin via pump ■ Rapid infusion can lead to cerebral edema ○ We monitor I & O to determine if their kidneys are still diuresing ■ NS and IV Reg insulin (break down sugars ASAP). @ BS of 200-350 we change to dextrose ½ NS. (we add dextrose b/c the insulin in the IV is causing BS to drop and it also decreases risk for Cerebral edema) ○ Monitory and careful replacement of potassium, based off most recent labs ■ K+: 3.5 - 5.0 Long term complications: 1. Diabetics have poor perfusion b/c sugar in blood tears into vessels and hardens/scars them; the elasticity is no longer good.. 2. Can’t break down fat so they are full of fat/ atherosclerosis. Diabetics will have HTN b/c heart doesn’t pump well and has to work harder and causing more pressure to the muscles = more vascular damage. ● Peripheral vascular disease: Peripheral vessels get clogged → no blood flow to feet or hands → possible amputation. Numbness and tingling. ● Retinopathy: Vision loss b/c vessels of the eye get damaged by high sugars that are not broken down. Leading to potential blindness. ● ● ● ● ● Neuropathy: Fat fills feet and fingers first → b/c the fat or hardening of vessels happens in smaller vessels/capillaries. ○ Tingling in fingers = no blood flow to the area. Lack/loss of feeling in the extremities. Angiopathy: Heart attack, HF, stroke. Arteries filled up to where they have MIs. Nephropathy: Too many ketones to glomeruli and can no longer repair itself and function → have to go on dialysis b/c kidneys won’t perfuse the way they should. Can lead to renal failure. Infections: Delayed wound healing - inorder to heal they need to profuse Mostly occur because of poor perfusion/circulation Nursing goals: ❖ Manage diabetes ❖ Maintain fasting BS < 125 ❖ Maintain HgA1C < 6.5% ❖ Preventing complications and lifestyle modifications Nursing interventions: ❖ Monitor BS (blood sugar) as ordered ❖ Monitor for signs of hypo/hyperglycemia ❖ Administer insulin as ordered Pt education (cont.) ❖ Importance of monitoring Blood Sugar ❖ Teach them how - show them the steps ❖ Diet ❖ Exercise ❖ Stop smoking Patient education: ● Sick day rules: ○ Blood Sugar rise when you are sick ○ Pts need to monitor BS more frequently. May need more meds or insulin based on their BS levels. ● Foot care: ○ Diabetic shoes: Thick leather soles with big toe box. Able to freely move their toes, no rubbing should occur. ○ NEED TO LOOK AT THEIR FEET DAILY. Wash and dry daily, especially between the toes. ○ Avoid extreme temperature: hot/cold. ○ Trimming of nails: ONLY podiatrist (foot doctor) can do this - NURSES CANNOT do this Lecture 3 Pulmonary disorders: RESPIRATORY SYSTEM Nursing diagnoses (3): impaired gas exchange, altered breathing patterns, ineffective airway clearance. Gas exchange at the alveoli: ● Exchange of gases occurs because of differences in partial pressures. ● Oxygen diffuses from the air into the blood at the alveoli to be transported to the cells of the body. ● Carbon dioxide diffuses from the blood into the air at the alveoli to be removed from the body. Assessment: ● Pulse ox ○ Normal > 90% ○ COPD >88% ● ABG’s - measures how well the gas exchange is ● Lung sounds - crackles can indicate fluid in the lungs → atelectasis. ● Pattern of breathing/Rate of breathing ● Looking at my chest. Look at Positioning: tri-pod - indicates air hunger History: ● Smoking/ Drug use ● Allergies ● Diet: sodium intake, can cause the pt to retain fluid in their lungs. ● Chest pain/Dyspnea (ADLs) ● Kussmaul’s respirations (rapid, labored, deep respirations) is r/t DKA or metabolic acidosis Respiratory focused assessment: ● ● ● Inspection: ○ Skin and nails: ■ Cyanosis: Not getting good gas exchange ■ Capillary refill: < 3 Sec ■ Clubbing: In heart and lung diseases that reduce the amount of oxygen in the blood. (COPD) ○ Head and neck: Hypertrophy (head and neck get large), have a barrel chest - COPD pts. Palpation: ○ Vocal/tactile fremitus (vibration): Indicates fluid that is there and not supposed to be there. ■ Vibration when pt speaks. ○ Crepitus: Crackling sensation under finger tips, like bubble wrap ■ Subcutaneous emphysema = air trapping in tissue Auscultation: ○ Normal breath sounds: ■ Bronchial (on expiration) ■ Bronchovesicular (on expiration and inspiration) ■ Vesicular (on inspiration) ○ Abnormal (adventitious) breath sounds: ■ Crackles (rales): popping, discontinuous sounds. ● ■ Indicate fluid in the lungs. End of inspiration and start of expiration Wheezes: squeaky, musical, continuous sound. End of inspiration and start of expiration ● Specific to asthma pts; due to bronchoconstriction –air can’t get through the airway. ■ Friction rubs: sounds similar to sand-paper ■ Rhonchi: Rumbling, lower-pitched, coarse, continuous snoring sound. Crackles begin to consolidate, resulting in more fluid in the lung. ■ Diminished lung sounds: If you don’t hear anything, air isn’t moving → lungs are consolidated. Diagnostics: ● ● Abg’s - tests blood gas exchange Pulse ox: #1 TEST. Fastest and actual indicator of oxygen status of the patient. ○ Good pulse ox number is > 90. ○ COPD: Chronic disease process that doesn’t allow for oxygenation to happen: >88% ● ● Pulmonary function test: For pneumonia and Tb patients. Tests how good the airway opens up. Sputum test: #2 TEST. Tell us whether an infectious process is happening (ex. Pneumonia) ○ Done in the morning when there is the most sputum. ○ Broad spectrum antibiotics are used while waiting until the sputum test results come back to determine how to tx the patient. ● Chest x-ray: Shows if there is something in the lungs, consolidation. ○ DOES NOT diagnose anything... Sputum test diagnosis. CT, MRI Fluoroscopic and Radioisotope procedures Bronchoscopy: Done when a good sputum culture was not obtained or chest x-ray shows more than just fluid in the lungs. ○ Lidocaine is sprayed to numb gag reflex, then a large scope is put in the throat. They get fluid samples to diagnose the issue. ■ It is usually cancer. ○ NPO for bronchoscopy → short-time, 4 hrs minimum. ○ Gag reflux must return before giving the patient any food/beverages. Patient is at risk for aspiration. Thoracentesis: Needle put in the chest and fluid is aspirated. ○ Pt sits over the table, causing lungs to expand to the greatest potential. Usually makes patients feel better to be on the bedside table. ○ High risk for pneumothorax, due to their punctured lung, and tracheal deviation (tracheal shifts to right or left) ○ What could occur 3 days after the procedure? Pt is at most risk for an infection. ■ S/S of infection: fever, high WBC ○ Nursing considerations after procedure: ● ● ● ● ■ ■ Tediously assess: lung sounds, RR, breathing, chest should be rising and falling. Assess pt every 15 minutes. Should be even and unlabored. Blood gas analysis: ● pH → 7.35-7.45 ● Carbon dioxide (CO2)→ 45-35. Lungs ● Bicarbonate (HCO3) → 22-26 Kidneys Respiratory acidosis: ● Pathophysiology → accumulation of CO2; CO2 is filling up in the body causing it to be acidotic. ○ This results in the formation of the carbonic acid. ● Causes: ○ Caused by Hypoventilation ○ Airway obstruction ○ Alveoli dysfunction Know the Causes side Respiratory alkalosis: ● Pathophysiology → excess elimination of CO2 ● Causes: ○ By hyperventilation ○ Mechanical ventilation Metabolic acidosis: ● Pathophysiology: excess acid in the stomach consuming HCO3 ● Causes: ○ Excess loss of HCO3 by GI tract - diarrhea ○ Renal failure ○ Kussmaul’s respiration (hallmark s/s) Know the Causes side Metabolic alkalosis: ● Pathophysiology: Accumulation of the HCO3 ● Causes: ○ Loss of normal body acids - how are these lost? Vomiting, ng suctioning ○ Excess administration of sodium bicarbonate ○ Hypokalemia ○ Vomiting and NG suctioning (biggest cause) Oxygen delivery: ● Room air: 21% ● Nasal cannula: Most common one we see ○ Delivers 24-44% (1-6L). ○ 4L max for COPD, they are at risk for oxygen toxicity. ● Face mask: 35-50% (6-12L) ● Venturi mask: Prevents O2 toxicity and provides the patient with room air and oxygen with the small openings in the mask. ○ Has better control of how much oxygen you are breathing. Delivers precise, highflow rates of O2. ○ Good for COPD pts. ● Non-rebreather: up to 100%, 15L Complications of oxygen therapy: ● Oxygen toxicity: Oxygen concentrations greater than 50% for extended periods of time (longer than 48 hours) can cause overproduction of free radicals, which can severely damage cells. ○ S/S: Includes non-productive cough, substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates on x-ray. Respiratory distress, confusion, hallucinations, sleepy (hard to arouse), anxious, and getting worse when increasing O2 levels. ○ COPD patients are at risk for oxygen toxicity. ○ If they have non-rebreather mask they are at high risk for oxygen toxicity - getting too much oxygen ● Prevention: ○ Starting at the lowest O2 level, 1L ○ PEEP or CPAP prevents or reverses atelectasis and allows lower oxygen percentages to be used. Nursing interventions with pulmonary patients: ● Position: High fowlers ● Hydration: Breaks down the thick mucous, so it can expel easier. ● Identify pollutants: For asthma patients, b/c pollutants/allergens can cause them to have more attacks. ○ Asthma patients always need to have their inhaler ● TCDB(turn, cough, deep, breath) ○ Will help patients cough up the secretions in their lungs. ● ● ● ● ● ● ■ Teach patient if they do not know IS: Device ensures that a volume of air is inhaled and the patient takes deep breaths. ○ Used to prevent/treat atelectasis ○ Should be done every 15 min or commercial break about 3-4x each. Around 8- 10x an hour. Pursed lip breathing Chest PT- Machine/nurse that pounds on the pt’s back to loosen secretions. Usually done for comatose pts, they could drown in their own secretions. Goals: ■ Removal of bronchial secretions. ■ Improved ventilation. ■ Increased efficiency of respiratory muscles. Suctioning: Elevating HOB What are these interventions called?! RESPIRATORY TOILET Artificial airways (Trach): Needed for airway disorders ● Provide for adequate oxygenation and ventilation ● Can depress swallowing and gag reflexes ● Increase risk for aspiration ○ HOB needs to be elevated ● Replacement trach and Ambu bag MUST BE AT BEDSIDE TRACHS: ● Goal: prevent infection → cleaning very good, routine trach care. ● Trach patient should ALWAYS be in Semi-fowler's position ● Prevention of tissue damage ● Humidification & air warming needed ● Suctioning: ○ STERILE procedure ○ NEVER longer than 10-15 seconds ○ Up to 2-3 suction passess ○ Minimize vagal stimulation ● Oral Care ● Site Care ○ Needed when visibly soiled TRACH complications: ● Complications include: bleeding, pneumothorax, aspiration, pneumonia aspiration ● Long-term complications include: airway obstruction, infection, rupture of the innominate artery, dysphagia, tracheal dilatation, and tracheal ischemia and necrosis. ● Difficulties with swallowing & communication Upper respiratory tract disorders: Rhinitis, sinusitis, laryngitis, pharyngitis ● Pathophysiology: ○ Viral: Hard to treat ○ It causes the inability to clear secretions which causes an infection ● Risk factors: ○ Asthma ○ Allergies ○ Deviated septum* ○ Stress ● Diagnostic: ○ Strep culture for pharyngitis ● Assessment findings: ○ Rhinitis/ sinusitis assessment findings: Think of allergies: sneeze, sniffles, congested ○ Pharyngitis ■ Red,swollen throat - like strep throat ■ White patches on throat ■ Enlarged lymph nodes ■ Fever ○ Laryngitis: ■ Hoarseness ■ Severe cough ● TREATMENT: ○ Expectorants: Expels mucus and helps cough it up. Used the most. ○ Mucolytics: Breaks down the mucus. Only works to thin secretions if you drink enough water. Used the most. ○ Antitussives: Stops the cough. ○ These meds can cause dizziness and HTN - so monitor BP, pt must get up slow ○ Laryngitis → rest the voice and avoid irritants Sleep apnea: put them on bipap or cpap. Pt education: ● Tell patient to avoid triggers and irritants ● Stop/avoid smoking Pneumonia: Droplet precaution ● Pathophysiology: ○ Infection of the lower respiratory tract caused by microorganisms ○ Results from fluid sitting in the lungs. ■ Exposure to foriegn matter → inflammatory response → capillary walls become “leaky”→ fluid shifts from capillaries to interstitial space, then alveoli → alveoli fill with fluid → lung tissue consolidates → poorly oxygenated blood returns to the heart and leads to arterial hypoxia. ● How pneumonia occurs: ○ Community - acquired: Occurs before the pt goes into hospital; developed at home ○ Hospital acquired → also known as Nosocomial: Occurs in hospitals, from patients not doing interventions→ IS. ○ Ventilator Acquired: If pt is on a ventilator and it is not taken care of properly ○ Health care associated: Hospital acquired ○ Immunocompromised: Chemo pts and anyone that is immunocompromised (HIV, AIDs). ○ Aspiration pneumonia: Pt aspirates and it goes into their lungs. This is peg tube, ng tube and trach patients. ● Aspiration pneumonia: ○ Risk factors: altered LOC, dysphagia, neurological disorder, recumbent position, artificial airways, enteral nutrition. ○ Goal is Prevention ■ Semi-fowler’s ■ Assess for N/V ■ Feeding tube placement assessment ● Assessment findings of Pneumonia: ○ Assessment findings: High Wbc, fever, high HR, Chills, High RR (trying to breath better), fatigued, lower BP, diminished breath sounds, productive cough (green or yellow). ■ Dyspnea ■ Pleural pain ■ Respiratory distress Diagnostic test for pneumonia: ○ Sputum culture: Assists in determining how to treat the infection and figuring out the correct antibiotic to use. ■ ALWAYS DONE IN AM ■ Always do culture before any antibiotics are given ■ Best diagnostic test. ○ WBC: Will tell us whether you have an infection but will not specify where, it is not definitive. ○ Chest x-ray: Will show if there is something in the lungs and whites it out. Further testing is almost always needed. ● ● ● ● ○ Bronchoscopy - last resort - it is invasive. Treatment: ○ Antibiotics ○ Can give broad spectrum antibiotics before sputum culture results are back to help start fighting the infection. Nursing interventions: ○ TCDB, hydration, Semi-fowlers, respiratory toilets. ○ Low O2 levels→ Elevate HOB Complications: Occur if the infection is not treated. ○ Sepsis ○ Septic shock Tuberculosis: Airborne precautions ● Pathophysiology: ○ Highly contagious - spread by airborne ○ Infectious disease affects lung parenchyma ● Acid fast bacilli grows slowly, resistant ● Granulomatous infection in lung surrounded by collagen, fibroblasts, & lymphocytes → necrosis develops into granular mass visible on x-ray ● Risk factors: ○ Health care workers ○ Drugs abusers ○ Immunocompromised ○ Inadequate healthcare ○ Malnutrition ○ Poverty ○ Overcrowding ● Assessment findings: ○ Hallmark assessment findings: Night sweats, weight loss, bloody sputum ■ If a patient comes in with these symptoms, isolate the pt and test for TB . ○ Fatigued, night sweats, lose wt, chest pain, temperature, bloody sputum ● Diagnostics: Mantoux skin test → chest x-ray → AFB ○ Mantoux skin test: ■ Inject antibody and if you have TB the antibody will react. Tests if you were exposed to TB. ● What do we do next if it is positive? Chest x-ray ○ Chest x-ray ■ Will show if there is something in the lungs - DOES NOT DIAGNOSE. If something is noted they will then send pt for AFB. ○ Positive acid-fast bacilli (AFB) ■ Confirms diagnosis of TB ● Demographic will determine pos or neg finding: PPDs done after 48 - 72 hours ○ >15 mm: general pop with no risk factors. Never been exposed to TB. ○ ○ ● ● ● >10 mm: drug abuser, long term care facility, socioeconomic risk factors, health care workers, residents of long-term care facilities. >5 mm: HIV, or immunocompromised patients that have had recent close contact with someone with active TB Treatment: Combination drugs (4 drugs): (6-12 months) ○ Isoniazid (INH)- High risk for liver toxicity. Avoid foods with tyramine (tuna, aged cheeses, etc). ○ Rifampin - Educate patients that bodily fluids will be orange. Alternate form of birth control will be needed, anything but the pill. High risk for liver toxicity. ○ Pyrazinamide ○ Ethambutol ○ Tb drugs can cause liver toxicity ■ Monitor liver enzymes ■ Monitor BUN and Creatine. ○ Educate pt that if they should not stop taking if they feel better. Nursing interventions: ○ First thing you should do if the patient comes in coughing with blood tinged sputum: Mask them ○ When you find out more information and suspect tb what should you do? Isolate the patient. ■ Isolation until sputum is free of bacteria: ● Patient will be in isolation until 3 negative AFB tests come back. ● Nurses need to wear N-95 masks. ● Isolated in a negative-pressure room. Pt education: ○ Isolation: Educate about the negative pressure room the pt will be in. ○ Medication: ■ Meds for 6-12 months. ■ Takes at least 3 months to see negative test results. ■ Medication side effects. ○ Lab work: Liver function test - routinely monitoring. ■ Med can be toxic to the kidneys. ■ Monitor LFT’s, BUN & creatine. Lower respiratory tract disorders: ● Atelectasis: Post op day 1 ○ Pathophysiology: ■ Collapse of the alveoli →lower oxygen supply to the tissue ■ Occurs 24 hours after the surgery ■ Loss of lung volume. ○ Risk factors: ■ Bed written, post op patients. ● Secretions begin to sit - most common cause. ○ Assessment findings: ○ ● ■ Dyspnea ■ Cough ■ Leukocytosis ■ Sputum production ■ Crackles ■ Decreased breath sounds Nursing interventions: ■ Prevention: IS, TCDB, Turn or ambulate ASAP, hydration, Nebulizer treatment, bronchodilators and mucolytics, Chest physiotherapy Pulmonary embolism: Occurs post op day 2. ○ Patho: If a nurse doesn’t do interventions with pt postoperatively, pt can get DVT → can turn into pulmonary emboli. Complication of ineffective nursing interventions for postoperative clients. ■ Blockage of pulmonary arteries by thrombus or fat, or air embolism or tumor tissue ○ Risk factors: ■ Not ambulating ■ Occurs in postop day 2 patients. ○ Assessment findings: ■ Impending doom - hallmark finding ■ Sudden chest pain ■ High RR ■ Low pulses ■ SOB ■ Dyspnea ■ Red, warm ■ Swollen ○ TX: ■ Clot treatment: treat clot → heparin (for short-term therapy). Long-term would be a blood thinner. ■ ↓Order of interventions ↓ 1. High Fowler’s 2. Oxygen 3. Bed rest 4. Call MD 5. Heparin/Coumadin:Heparin always gets its own IV line. Disorders of chronic airflow limitation: ● Asthma ○ Patho: Inflammation and constriction of the airway. ■ Reversible airflow obstruction caused by diffuse airway inflammation and constriction when exposed to irritant. ■ ■ ■ ○ ○ ○ ○ Triggers Acute closure Body has allergen → body reacts by coughing/sneezing → body then creates mucus to protect/cover things → blocking of airway → need to get rid mucus to breathe Risk factors: ■ URI ■ Allergens ■ Weather change ■ Exercise ■ Pollutants Assessment findings: ■ Wheezing: Very end of inspiration and start of expiration. ■ Coughing: Earliest clinical manifestation and 1st sign that the patient is improving. ■ SOB Tx: ■ Bronchodilator (ex. Albuterol, Turbutaline (brethine): ALWAYS given 1st ● SE: Tachycardia (check HR before giving drug) ● For Acute asthma ● Open up the bronchioles and relax the smooth muscles. ● Drug is effective once wheezing has resolved ■ Inhaled corticosteroid → pulmicort (Budesonide): decreases inflammation ● Steroids are for long term management for asthma. ● Chronic asthma management ● Wait 2-5 min after administration of bronchodilator then administer corticosteroid. ● Teach patients to rinse mouth after inhaling the drug because they can get thrush (oral candidiasis). ■ Advair and spiriva → long term management drugs ● Advair works in the inflammation part. Spiriva works on the bronchospasm part. ● Long acting beta 2 agonists and inhaled glucocorticoid. ● SE: Dry mouth ○ Teach patients to suck on candy to help with the dry mouth ● Inhale that powder Drugs are effective once clear lung sounds are heard. ■ Histamine to help reduce the allergens. ● Prevents constriction in the airway ■ Anticholinergics Intervention: ■ Avoid pollutants ■ STOP smoking ■ Avoid triggers ■ ● ● ● ● Exercise: Excessive balls to the walls exercise. Encourage them to slow it down but not avoid exercise. ● Histamines can help. COPD: ○ Pathophysiology: ■ Air gets trapped in the lungs and converts to CO2, the patient stops breathing because of too much CO2. Characterized by chronic airflow limitation not fully reversible. ● Must do something to get the airway open! ■ Emphysema: Loss of the elasticity of the alveoli; very weak and flabby. ■ Chronic bronchitis: rigidity of the airway due to chronic inflammation and scarring. No movement going on. ● Rhonchi and wheezing present b/c they hold onto secretions. Risk factors: ○ Smoking ○ Allergens ○ Air Pollutants ○ Recurrent infection ○ Genetics ○ Environmental / occupational factors ○ Aging Assessment findings: Need to know early from late. ○ Hallmark sign: Barrel chest ○ Thin: b/c they can’t catch their breath to eat, because it tires them out. ○ Tripod positioning: air hungry, always trying to get air. ○ History, physical exam, PFT’s ○ Dyspnea (Late) ○ Chronic cough ○ Sputum production ○ Diminished breath sounds ○ Prolonged expiration ○ Rhonchi & wheezes [Main ones: Clubbing, barrel chest, lots of accessory muscles (late)] ○ ● Watch for signs of respiratory failure! These are all late ■ Severe dyspnea unresponsive to treatment ■ Alternating tachypnea & bradypnea and apnea – fatigue ■ Hyperventilation ■ Anxiety ■ Change in mental status ■ Worsening hypoxia despite oxygen therapy ■ Worsening hypercapnia ■ Use of accessory muscles Nsg management - COPD: Goals – monitor disease, reduce symptoms, promote maximum lung function, prevent premature disability ○ Nursing interventions: ■ Pursed lip breathing: increases the pressure and forces the air out of the lungs. ■ Oxygen: Start w/ 1L, if that does not increase O2 sats to 88% then go up to 2L. Then follow this process up to 4L. NEVER go more than 4L. ● Nasal cannula: start with this this first ● Venturi mask: this is 2nd. Opening helps prevent oxygen toxicity. Provides the patient with room air and oxygen with the small openings in the mask. ● CPAP/BIPAP: This provides a high amount of pressure to lungs, it is noninvasive. Great way to stop/prevent oxygen toxicity to occur. ● High calorie small meals because they get tired when eating. Meals that are easy to chew so they don’t use as much energy. ○ Patient education ■ Steps to prevent and control acute attacks:pursed lip breathing, inhaler, tripod position, diaphragmatic breathing ● Hydration: Lots of water to try to get rid of pulmonary secretions ● Pulmonary toilet: TCDB techniques ■ Coughing/deep breathing: Getting rid of junk in their chest ■ Conserving /maximizing energy for activities: Pace daily activities, simple activities (walking) ■ Minimizing exposure to allergens/irritants: Humidifier and avoid triggers. ■ Smoking cessation. ■ Encourage them to participate in rehab programs and support groups ■ Preventative interventions: Recognize early signs of infections: Fever, flu-shots, quit smoking, annual pneumonia vaccine ○ Medications ■ Bronchodilators ■ Inhaled Corticosteroids ■ Antibiotics - when they get an infective process these are used. ■ Antipyretics ■ Anticholinergics ○ ○ ○ ○ Nutrition - High calorie small meals → so they don’t use that much energy with the small meals Pulmonary Rehab Supplementary oxygen – monitor flow rate carefully!! Surgical treatments