Exam 1 Study Guide Module 1-3
Medication Effect on Surgery
Corticosteroids
Risk if increased BG
Diuretics
Phenothiazines (thorazine)
Insulin
Antibiotics
Anticoagulants (Aspirin, coumadin)
Risk of bleeding
Antidote for Warfarin → Vit K
Opioids (morphine, oxycontin)
Risk of respiratory depression
OTC meds
Risk of interactions
Gerontological considerations
● Higher risk of complications from anesthesia and surgery due to:
○ Age related cardiac and pulmonary changes
○ Decreased tissue elasticity and lean tissue mass
○ Decreased kidney function and liver clearance of anesthetic agents
○ Impaired ability to increase metabolic rate and compared thermoregulatory mechanisms
Heparin Induced Thrombocytopenia (HIT)
● Immune mediated adverse drug reaction caused by the emergence of antibodies that activate
platelets in the presence of heparin → potentially lethal
● Nursing interventions: Stop all heparin, send blood samples to lab, initiate alternative
anticoagulation, monitor platelet count (don't use warfarin until they recover)
● Do not administer prophylactic platelet transfusions as it may exacerbate the hypercoagulable
state unless the patient develops bleeding then it may be considered
Bleeding Disorders
●
●
●
●
Must be educated to monitor themselves frequently for any S&S of bleeding such as petechiae and
ecchymosis
Examine nose and gums for bleeding (possibly rectum and sputum)
○ When severe and hospitalized → monitor for bleeding by testing all drainage, feces, urine,
emesis, and gastric juices for obvious or occult blood
Must avoid activities that increase the risk of bleeding such as contact sports
​Patient had high hemoglobin and hematocrit but there was no blood loss, where would you
look to see if they are bleeding? → check their stool for signs of internal bleeding
Blood Transfusion: Assessment
● Pre-Assessment
○ Baseline vitals, taken periodically once transfusion starts based on protocol
○ Kidney function, cardiovascular, lung sounds
○ Evaluate IV site, gauge of needle
■ 18 gauge needle for rapid
■ 20 gauge needle for slow (smaller can risk hemolysis)
○ Blood product matches patient
● Universal Donor: O● Universal Recipient AB+
○ RBCs must be ABO and Rh compatible
● Pt identification
○ Identify unit label of blood and patient by TWO nurses before hanging blood
○ Check for expiration by TWO nurses (both nurses must document that check occurred)
● Equipment
○ Y-set filtered
■ 2 drip chambers (1 port with normal saline turn off saline once blood is started)
○ Normal saline in first port, RBCs in second port
● Procedure
○ Check blood for gas bubbles and any unusual coloring
○ ​RBCs should be infused within a 4-hour period
○ RBCs should be hung within 30 mins of obtaining from blood bank
○ Monitor closely for 15-30 mins to detect signs of a reaction
○ Change blood tubing every 2 units transfused to decrease chance of bacterial contamination
● S&S of adverse reaction: restlessness, hives, N/V, torso or back pain, SOB, flushing, hematuria,
fever and chills → stop infusion immediately, notify primary provider, and follow reaction protocols
● Postprocedure
○ Obtain vitals and breath sounds and compare with baseline
○ Monitor at risk patients for at least 6 hours for sign of transfusion reaction or
transfusion-associated circulatory overload (TACO)
○
*The only solution you should use to prime the line when hanging RBCs is NORMAL SALINE
*Never add medications to blood or blood products
Acute Hemolytic Transfusion Reaction
Most serious and life-threatening reaction → EMERGENCY
Occurs after infusion of incompatible RBCs
● Leads to activation of coagulation system and release of vasoactive enzymes that result
in vasomotor instability, cardiorespiratory collapse, and DIC
Signs/Symptoms: fever, hypotension, lumbar, flank, chest pain, face flushing, bleeding,
tachycardia/tachypnea, shock, cardiac collapse, DIC
Interventions: STOP TRANSFUSION, DISCONNECT tubing completely, Infuse NS,
DO NOT GIVE MORE DONOR BLOOD, Monitor need for dialysis, Call provider
ASAP
Prevention:
Extreme care during identification process
Don’t give the wrong blood!
Chemotherapy
●
●
Alopecia pg.1733
○ Obtaining a wig before hair loss begins can help decrease emotional trauma
○ Familiarity with scarves and turbans can also minimize distress
○ Reassure that hair will grow back after treatment, although color and texture might be different
Bone pain is the number one subjective sign of metastasis
Leukemia
★ Uncontrolled proliferation of WBC’s
★ Complications
○ Anemia, Infection, bleeding/DIC, renal dysfunction, tumor lysis syndrome
★ Ecchymosis and Petechiae
■ Must check patient’s most recent platelets levels → if low, discontinue any
antiplatelets or anticoagulants
★ Nursing Interventions: preventing infection, management of mucositis, improving nutritional intake
(small frequent feedings), acetaminophen for fever and pain, balance activity and rest, maintain
F&E, improve self care, manage anxiety and grief
★ Discharge Education: clear understanding of disease and how to monitor complications, information
on infection prevention, information on hospice and transitional care
Multiple Myeloma
Malignant disease of the most mature form of B lymphocyte- plasma cell
● Incidence increases with age; median 70 years old ; no cure
● Increase in osteoclast production → pathological fractures
● Manifestations
○ hyperCalcemia
○ Renal dysfunction
○ Anemia
○ Bone destruction → bone pain (back or ribs)
○ uncharacteristic fatigue, and bone pain in the back,pelvis, and knees with no trauma
● Treatment
○ Auto HSCT
○ Chemotherapy and radiation
○ Corticosteroids
● New drugs
○ Immunomodulatory drugs, thalidomide analogs, monoclonal antibody
● Nursing Interventions
○ Warn pts to avoid extreme temps
○ Gentle massage
○ Ambulation and appropriate footwear
○ Stool softeners and laxatives
○ Avoid activities that may cause injury
○ Give NSAIDs→ Monitor renal function
○ Assess S&S of hypercalcemia
Hypoproliferative Anemia
Defect in the production of RBCs
Iron deficiency anemia
● Iron replacement therapy, associated with pica, abdominal pain
● Low iron, ferritin, fatigue
● Patient education: stay away from traumatic events, sharp objects, razors to decrease risk of
bleeding
Anemia in renal disease
● Erythropoiesis-stimulating agent (ESA)
Anemia of inflammation
● Treat underlying disease, blood transfusion, intravenous iron supplementation
Aplastic anemia
● Prevent bleeding, infection
● Promote rest, adequate perfusion
Megaloblastic anemia
● Folic acid deficiency
● Vitamin b12 deficiency
● Sore, beefy, red tongue
Hemolytic Anemia
Sickle Cell
➔ Lack of oxygen due to RBC being sickled shape and can't properly attach
➔ Sickle Cell Crisis: Cells are sickling, decreases perfusion, increased pain
◆ Treatment: Pain medication first, blood transfusions,provide oxygen
➔ Patient education
◆ Do not swim in cold water, wear warm clothing, treat infections ASAP, avoid smoking
and alcohol
◆ Triggered by cold
◆ May experience fatigue due to low hematocrit
➔ Medication management
◆ Correct or control the cause, transfusion of RBCs, treat specific type of anemia
◆ Hematopoietic stem cell transplant
◆ Hydroxyurea decreases sickle formation
◆ IV opioids for pain
◆ Folic acid for increases erythropoiesis
*Anemia is present with hgb values between 5-11
Polycythemia
➔ Increased volume of RBCs
➔ Hemoglobin and hematocrit are elevated more than 50%
➔ Management
◆ Treatment not needed if condition is mild
◆ Therapeutic phlebotomy
➔ Nursing Interventions
◆ Avoid things that deprive body from O2
◆ Avoid tight, restrictive clothing on the legs, ROM to prevent clots
Disseminated Intravascular Coagulation (DIC)- pg 931
➔ Not a disease but a sign on underlying disorder caused by abnormal activation of the clotting
pathway, causing excessive amounts of tiny clots to form inside organs
➔ Triggers
◆ sepsis , trauma, shock, cancer, abruptio placentae, toxins, allergic reactions
➔ Altered hemostasis mechanism causes massive clotting in microcirculation
◆ As clotting factors are consumed → bleeding occurs
➔ Symptoms are related to tissue ischemia and bleeding
➔ S&S: low platelets (petechiae formation), high PT and aPTT, subQ hematomas, bleeding in
joint spaces
➔ Treatment
◆ Treat underlying cause, correct tissue ischemia, replace coagulation factors, use
Heparin
➔ Medications
◆ Heparin therapy, heparin-induced thrombocytopenia, LMWHT, warfarin, pradaxa
Breast
● Self Assessment should be done 5-7 days after menses → first week after menstruation
○ may result in early identification of problems and may also result in more diagnostic
workups for problems
● Variations in breast tissue occur during: the menstrual cycle (increased tenderness and
lumpiness), pregnancy, and the onset of menopause
● Abnormal Findings: skin dimpling, creasing, retraction signs, increased venous prominence,
paeu d’orange (edema), nipple inversion, acute mastitis
● Mammograms should be done annually after the age of 40
● Fine needle biopsy is used for absolute diagnosis
Stages/Survival
Stage 0
● Abnormal cells in duct lining or sections of the breast → increased risk of developing cancer
○ 100% survival rate
Stage 1
● Cancer in breast tissue → tumor is less than 1 inch
○ 98% survival rate
Stage 2
● Cancer in breast tissue → tumor is less than 2 inches and may spread to axillary lymph nodes
○ 88% survival rate
Stage 3
● Cancer in breast tissue and lymph nodes → tumor is larger than 2 inches, possible dimpling,
inflammation, and skin color changes
○ 52% survival rate
Stage 4
● Cancer has spread beyond the breast to other nearby areas
○ 16% survival rate
Mastectomy
●
Cancerous lesions are non-tender, fixed, and hard with irregular borders
●
Entire breast is removed, including all of the breast tissue and sometimes other nearby tissue
●
Patient education: avoid strenuous activity, lifting >10 pounds, and vigorous exercise until stitches are
removed. Also avoid BP cuffs and tight fitting clothes (for lymph node removal), no driving until drain is
removed and ROM is established. Don’t cut cuticles. If reconstruction occurs, don’t bathe until drain is
removed. Should do arm exercises on the affected side. Resume light housework after 6 weeks, no
lifting arm above nose
●
Management: stop any medications that may lead to hemorrhage (antiplatelets)
●
Risk of hemorrhage post op: decreased BP, increased HR, decreased urine output, decreased LOC,
cold clammy skin
Cervical Cancer
Associated with long lasting HPV infection
●
Risk factors: early child bearing, HPV, HIV,
obesity, prolonged use of contraceptives
●
S&S: irregular vaginal bleeding, pain, weight
loss, anemia
●
Detected by PAP smear
●
Prevention: HPV immunization, encourage
delay in first intercourse, smoking cessation,
Vitamin D and calcium supplementation, safe
sex
●
Treatment: surgery, chemo, radiation, or both
→ treatment may be palliative or curative
Ovarian Cancer
Leading cause of gyno deaths → silent killer
●
Risk factors: family history (most
significant),older age >40, early menarche,
late menopause, obesity, never been
preganant, BRCA1 and BRACA2
●
Prevention: long term use of oral
contraception
●
Treatment: surgery, chemo, palliative care →
treatment may be palliative or curative
●
Patient education: safety and prevention of
injury with radiation therapy
Radiation Therapy Precautions
➔
➔
➔
➔
Follow specific precautions related to time (30 minute max), distance (6 feet) and shielding
Film badges to monitor staff exposure
No pregnant visitors or visitors under 18 years
Minitor that device is not dislodged, if it is do not touch it and notify radiation safety
Pelvic Inflammatory Disease
● Inflammatory condition of the pelvic cavity that may begin with cervicitis and involve other
parts of the reproductive tract
● Gonorrhea and chlamydia are common causes → usually multiple organisms present
● S&S: discharge, dyspareunia, lower abdominal pain after voiding
● Treatment: broad spectrum antibiotics, treat sexual partner to prevent reinfection, analgesics,
rest and nutrition
● Patient Education: appropriate use of antibiotics, how to prevent reinfection, explain how
infection occurs, symptoms of ectopic pregnancy (life threatening) and use of condom to
prevent infecting others
Pg 1684
Hormone Replacement Therapy
● Medication that contains estrogen or estrogen and progesterone to replace what the body is
no longer making after menopause
● Treats hot flashes and night sweats during menopause
● Use lowest dose for shortest amount of time possible to decrease complications
● Contraindications: history of breast, endometrial or uterine cancer, vascular thrombosis, liver
disease, undiagnosed abnormal vaginal bleeding, fibrocystic breast disease, gallbladder
disease, high risk or history of blood clots and heart disease/strokes
● Patient education: high risk of DVT and PE
Prostate Cancer
Early Detection/ Education
● Symptoms of metastasis may be first sign
→ constant ache in hip and leg bones
Risk factors: increased age, family history, AA,
diet high in red meat,fatty or dairy
● Early identification: routine repeated DRE
and PSA testing
S&S: urinary obstruction, blood in urine or semen,
painful ejaculation
● For men with family history: Digital rectal
exam >45 years. Testicular self exam >40
years and regular PSA testing.
Treatment
●
●
●
●
Therapeutic vaccine
Prostatectomy
Radiation and/or chemotherapy
Hormonal therapy
ICP chart 63.5
➔ Early manifestations
◆ Changes in LOC, pupillary changes,
weakness in extremities, headache
➔ Late manifestations
◆ Cushing Triad (brady,HTN,apnea)
◆ Decorticate, decerebrate(worse)
◆ Cheyne stokes breathing and crackles
◆ Loss of brain stem reflexes
(pupil,gag,corneal, swallowing)
➔ NORMAL ICP: 10-20
◆ ↑ICP indicates head trauma → shifted or
Prostatectomy
●
Partial or complete removal of the prostate
●
Patient is placed in lithotomy position with
compression socks to decrease risk of DVT
●
Continuous irrigation used to prevent clots →
drainage begins as reddish pink but should
clear to a light pink within 24 hours after
surgery
●
Patient education:, maintain drain system,
monitor urine output, instruct to stand and
walk to voiding, how to prevent infection and
bleeding. It is normal to have dribbling post op
for upto a year → do kegals
○ Contact provider if there is blood in the
urine, decreased urine output, fever, or
calf tenderness
CCP
➔ Normal CCP is 60-100
◆ Less than 50 indicates perm.
neurologic damage
➔ CPP= MAP- ICP
➔ Maintain CCP by decreasing ICP and
supporting MPA through fluid administration
displaced CSF
◆ > 20 requires intervention → ischemia,
cell death, and herniation
➔ Interventions
◆ Elevate HOB 30-45 degrees
◆ No neck twisting or flexing
◆ No straining or valsalva maneuver
◆ Administer O2
◆ Maintain body temp and F&E balance
◆ PRN benzodiazepines
◆ Lumbar punctures are contraindicated
◆ Exhaling → decreased CO2 →
vasoconstriction
Subdural Hemorrhage
● Between the dura tissue and brain
● Acute or within 2 weeks
○ Slow bleed developing
● Treatment: remove the clot
Intracranial Hemorrhage
● Bleeding within the actual brain
● May be traumatic or non traumatic cause
● Measure ICP
Epidural Hemorrhage
● Collection of blood in the space between the skull and dura later
● Immediate loss of consciousness → then returns→ change in LOC
● Treatment: reduce ICP→ burr holes, craniotomy
Subdural Hematoma
●
●
●
Blood collection between dura tissue and brain
tissue
Could either be acute (24-48 hours) or a
prolonged (weeks to months) bleed that
progresses
Treatment: requires immediate craniotomy to
Epidural Hematoma
●
●
Blood collection in the space between the
skull and dura
Immediate loss of consciousness followed by
regaining of consciousness and then later
loss of consciousness again as hematoma
expands and ICP increases
control ICP if in acute phase or evacuation of clot
if chronic phase
●
Treatment: medical emergency → will need
surgery to remove clot, decrease ICP, and
burr holes or craniotomy to stop the bleeding
Spinal Cord Injury- 2078-2079
★ Spinal Shock → sudden depression of reflexes activity below level of spinal injury → flaccidity
and lack of reflexes
★ Neurogenic Shock→ loss of ANS function → decreased BP, HR, CO and venous pooling
★ Contractures
○ PROM → should be implemented ASAP after surgery 4-5x per day to prevent
○ Can develop rapidly with immobility
★ Complications
○ Disuse syndrome, autonomic dysreflexia, bladder and kidney infections, VTE or PE
(give anticoagulants), resp. impairment, UTI, orthostatic hypotension, sepsis,
pneumonia
★ Patient discharge education
○ Identify s+s of complications, sources of support, state lifestyle changes and how to
contact all members of treatment team
Autonomic Dysreflexia
Spinal cord lesions above T6
Manifestations
Pounding headache, ↑ BP, diaphoresis above level of injury, cold clammy skin below
level of injury with red blotches, N/V, nasal congestion, bradycardia
Exaggerated ANS response → acute emergency
Occurs after spinal shock has resolved → may occur years after injury
Triggered by distended bladder, stimulation of the skin, constipation
Interventions: Place in sitting position to lower BP, assessment to identify and eliminate
cause, catheter to empty bladder, administer ganglionic blocking agent
Seizure Interventions
● Patient safety is priority
● Maintain airway → DO NOT force or put fingers/objects in patient’s mouth during seizure
● Protect head
● Document events leading to seizure, during seizure, and after seizure
● Never leave patient’s side during an episode
● Instruct patient to follow a keto diet → high protein and fat, low carbs
Altered LOC
● Level of consciousness is the most important indicator of pt’s condition → continuum of normal
alertness to come
○ Earliest sign of increasing ICP is change in LOC
● Do GSC to assess verbal response, alertness, motor response, respiratory status, and
reflexes → most sensitive indicator of nero function
● Interventions: maintain airway (elevate HOB 30 degrees in lateral or semi prone position),
protect injury, fluid volume balance, CPT
○ Major goals: compensate for the pt’s loss of protective reflexes
Lab Values
❖ Hemoglobin:
➢ Female: 12-16 gm
➢ Male: 14-18 gm
❖ RBC: 4.5-5.0 million
❖ Hematocrit:
➢ Female: 37-47
➢ Male: 40-54
➢ Low levels Indicate a decrease in
RBC production
❖ Platelets: 150,000-450,000
❖ aPTT: 30-40 secs
❖ PT: 11-13.5 secs
❖ INR: 0.8 -1.1
❖ WBC: 4,000-11,000
❖ ICP: 10 to 20
❖ CCP: 60-100
End of Life care
● Nurses do not have the capacity to give outcomes to patients only doctors have
that ability
○ Be careful how you clarify for patients, only giving definitions and not any
outcomes
o Role is to be supportive and give supportive information, don’t re
answer the question, bring the care team back in to support that patient
● If a patient is a DNR, and their family decides once they are not conscious that
they want to save the patient, you cannot agree must follow patients DNR or will
or the request of the patient if they are of sound mind