NURSING SCIENCE TEST 2 BLUEPRINT!
PRE-OP vs POST OP:
Pre-operative: Time from when a decision is made to have surgery until they are in the
OR bed.
Post-operative: From post-anaesthesia room until d/c from health care.
PRESSURE INJURY STAGING:
Staging of Pressure Injuries:
Stage I: Non-blanchable erythema of intact skin
Staging of Pressure Injuries:
Stage II: Partial-thickness skin loss with exposed dermis
Staging of Pressure Injuries:
Stage III: Full thickness skin loss
Staging of Pressure Injuries:
Stage IV: Full-thickness skin and tissue loss
Staging of Pressure Injuries:
Unstageable: Obscured full-thickness skin and tissue loss
MRSA:
Drug Resistant Infections are usually nosocomial.
Methicillin-resistant staphylococcus aureus MRSA. (Drug resistant infection and
nosocomial).
MRSA is a cause of staph infection that is difficult to treat because of resistance to
some antibiotics. Staph infections such as MRSA can spread in hospitals, other health
care facilities, and communities where one lives, goes to work or school.
Symptoms of MRSA include: Skin can appear red, swollen, painful, bumps, warm to
touch, full of pus or drainage, accompanied by fever.
SOMATIC PAIN:
-Nociceptive pain SOMATIC: Aching or throbbing
-Localized
Arises from bone, joint, muscle, skin, or connective tissue.
NEUROPATHIC PAIN:
-Damage to peripheral nerve or central nervous system.
-Burning, shooting, stabbing, or electrical in nature
-Sudden, intense, short-lived, or lingering.
BREAKTHROUGH PAIN:
-Transient; moderate to severe
-Occurs beyond treated pain.
-Usually, rapid onset and brief duration with variable frequency and intensity.
IMAGERY:
-Imagery can be used as a nonpharmacological therapy for pain and it is considered to
be a cognitive technique.
PAIN IN CHILDREN:
-Strong link between nurse, child & family
-Need to build trusting relationship
-CAN express their pain
-Withholding narcotics for fear of addiction is unfounded
PAIN IN ELDERLY:
-Elderly Pain is under-appreciated in the elderly (assume it’s normal)
-Very little studies have been done on pain in the elderly
PCA:
A method of pain relief in which the patient controls the amount of pain medicine that is
used. When pain relief is needed, the person can receive a preset dose of pain
medicine by pressing a button on a computerized pump that is connected to a small
tube in the body. Also called PCA.
SHOCK:
-Shock is failure of the cardiovascular system to maintain adequate perfusion of vital
organs
-Imbalance in supply/demand for O2 and nutrients.
There are different types of shock, as follows:
Classification of shock
1.Cardiogenic
2.Hypovolemic
3.Distributive
4.Obstructive
LOW BLOOD FLOW CARDIOGENIC:
-Systolic or diastolic dysfunction
-Compromised cardiac output (CO).. Precipitating causes
-Myocardial infarction
-Cardiomyopathy
-Blunt cardiac injury
-Severe systemic or pulmonary hypertension
-Cardiac tamponade
-Myocardial depression from metabolic problems……Early manifestations
-Tachycardia
-Hypotension
-Narrowed pulse pressure
↑ myocardial O2 consumption….
LOW BLOOD FLOW HYPOVOLEMIC SHOCK:
Absolute hypovolemia: Loss of intravascular fluid volume.
-Hemorrhage
-GI loss (for example, vomiting, diarrhea)
-Fistula drainage
-Diabetes insipidus
-Hyperglycemia
-Diuresis
Relative hypovolemia:
-Results when fluid volume moves out of the vascular space into extravascular spaces
(for example, interstitial or intracavitary space)
-Termed third spacing
LOW BLOOD FLOW HYPOVOLEMIC SHOCK: Responds to acute volume loss
depending on the following: Extent of injury or insult, age, general state of health,
clinical manifestations, anxiety, tachypnea, increase in CO, heart rate, decrease in
stroke volume, PAOP, urinary output, if loss is more than 30% blood volume is
replaced.
DISTRIBUTIVE SHOCK
NEUROGENIC SHOCK: Hemodynamic phenomenon that can occur within 30 minutes
of a spinal cord injury at the fifth thoracic (T5) vertebra or above and can last up to 6
weeks.
-Can occur in response to spinal anesthesia
-Results in massive vasodilation, leading to pooling of blood in vessels
DISTRIBUTIVE SHOCK
Anaphylactic Shock: Acute, life-threatening hypersensitivity reaction.
Clinical manifesations: Anxiety, confusion, chest pain, sense of impeding doom,
dizziness, incontinence, swelling of lips and tongue angioedema, wheezing stridor,
flushing, pruritus, urticaria, respiratory distress and circulatory failure.
DISTRIBUTIVE SHOCK
SEPTIC SHOCK:
Sepsis: systemic inflammatory response to documented or suspected infection
Severe sepsis = sepsis + organ dysfunction
Presence of sepsis with hypotension despite fluid resuscitation
Presence of tissue perfusion abnormalities
Clinical manifestations:
-Coagulation
-Inflammation
-Fibrinolysis
-Formation of microthrombi and obstruction of microvasculature
-Increased CO
-Tachypnea
-Hyperventilation
-Temperature dysregulation
-Urine output
-Altered neurological vital status
-GI dysfunction
-Respiratory failure is common
General clinical manifestations:
Treatment:
-Need MD
-Stabilize respiratory status
-Need O2 or intubation
-IV fluids - What type?
0.9% NaCl
plasma, albumin, blood
-Medications
Vasoconstrictor ex. dopamine
-Cardiac output enhancer ex. dobutamine
-Trendelenburg
Collaborative care:
-Cornerstone of therapy for septic, hypovolemic, and anaphylactic shock = volume
expansion.
-Isotonic crystalloids (For example, normal saline) for initial resuscitation of shock.
POST OP COMPLICATIONS:
-Nausea, vomiting, shock, anesthesia side effects, pain, breathing problems,
constipation and gas, breathing problems, insomnia, urinary retention, fever, surgical
infection, wound infection, hemorrhage, deep vein thrombosis.
DEEP BREATHING AND COUGHING:
Deep breathing and coughing techniques;
-Help prevent alveolar collapse
-Help move respiratory secretions to larger airway passages for expectoration
-Three to four deep breaths every 5 to 10 minutes
-Incentive spirometer is helpful in providing visual feedback of respiratory effort.
-Splinting abdominal incision provides support to the incision and aids in coughing.
POSITIONING DURING SURGERY:
-Musculoskeletal system
-Identify joints affected with arthritis
-Mobility restrictions may affect positioning and ambulation
-Bring mobility aids to surgery
-Report problems affecting neck or lumbar spine, can affect airway management and
anesthesia delivery.
INFORMED CONSENT:
-Informed consent is a document that must be signed by the client or client
representatives that gives permission for treatment.
-Consent also states that the client is aware of the treatment & possible complications.
Informed consent must include;
-Adequate disclosure
-Understanding and comprehension
-Operative consent must be signed before any preoperative medication is given
-Voluntarily given consent
-Client’s signature must be witnessed
-Surgeon is responsible for obtaining consent
-Nurse may obtain and witness signature
-Document in client chart
-Verify client has understanding
-Client’s permission may be withdrawn at any time
-Legally appointed representative of family may consent if patient is:
A minor
-Unconscious
-Mentally incompetent
-Medical emergency may override need for consent
-Capable minors
CHAIN OF INFECTION:
1.
2.
3.
4.
5.
6.
Infectious agent or the microorganism which can cause disease.
Reservoir or source of infection where the microorganism can live and thrive.
Portal of exit from the reservoir.
Mode of transmission.
Portal of entry.
Susceptible host.
NOSOCOMIAL INFECTIONS / Health Care-Associated Infections:
Locations:
- Urinary tract infections account for 45 percent of all nosocomial infections,
Pneumonia accounts for 15 percent, Surgical wounds account for 30 percent,
Bacteria’s accounts for 7 percent, and Anti-biotic associated diarrhea accounts for 3
percent.
DRUG RESISTANT INFECTIONS:
-Usually nosocomial
JP VS HEMOVAC DRAIN:
DRESSING CHANGES:
TYPES OF DRAINAGE:
1.Exudate – fluid or cells that escape from blood vessels during inflammation
2.Serous –clear yellow
3.Purulent – thick, opaque (can be foul smelling!)
Beige, white, grey, green…
4.Sanguineous –dark brown, dark red or bright red
5.Sero-sanguineous – mixture of serous & sanguineous fluids
WOUND COMPLICATIONS: Infection
-Contaminated wounds & wounds from bowel surgery are more likely to become
infected
-Redness, heat, pain, swelling, purulent & increased drainage, increased T, increased
WBC
-Hemorrhage
-S/S lo BP, rapid RR, rapid & weak pulse, cool, clammy skin
-Apply pressure (if external bleeding)
-obtain V/S
-notify MD STAT
DEHISCENCE and EVISCERATION:
Dehiscence;
-Layers of tissue are pulled apart
-Apply a dry dressing until MD examines wound
Evisceration;
-Protrusion of organs through the surgical incision
-Both above are serious and require immediate MD notification ***
-Often feels as if “something let go”
-Cover wound with sterile normal saline soaked gauze
-Monitor V/S & report changes ASAP
NURSING DIAGNOSIS:
This can vary depending on what the nurse is assessing, whether its pain, wounds,
surgical infections, etc. Refer to PowerPoints for examples, if needed.