N444: Test 4

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N444: Test 4 by Mind Map: N444: Test 4

1. Surgery

1.1. Pre-Operative Phase

1.1.1. Various types of surgeries Purposes Urgency Degree of risk Extent Place

1.1.2. Pre-admission testing Initial pre-op assessment begins Nutritional and fluid status Dentition Substance use All medication use Psychosocial factors Review of systems Special considerations Health history Involves family in interview Verifies completion of diagnostics CBC, chems Urinalysis, pregnancy test PTT, PT/INR Blood glucose Type/screen vs. Type/cross-match EKG Chest x-ray Verifies understanding of pre-op orders

1.1.3. Informed consent Voluntary, in writing Must be obtained by the surgeon Adequate disclosure Procedure Risks, benefits, alternatives Unusual procedure disclosure Nurse's role Obtained before psychoactive medication Verify patient's understanding Obtain and witness signature Can't be given by incompetent patients Not autonomous Cannot give or withhold

1.1.4. Patient education Deep breathing Coughing Incentive spirometry Mobility Pain management Cognitive coping strategies Ambulatory instructions Day-of-surgery instructions Where/when to report NPO status (except some medications) No substance use for 24 hours prior No makeup, jewelry, valuables Loose clothing

1.1.5. Nursing interventions General Psychosocial Safety Nutrition, fluids Bowel and skin preparation Immediate Pre-anesthetic medication Pre-op record Transport Family needs Preventative Diaphragmatic breathing Coughing Leg exercises Turning to side Getting out of bed Post-surgical Pain management Respiratory interventions Positioning Early ambulation Dietary restrictions Equipment Expected length of stay Outpatient surgery*

1.1.6. Transferring to the OR Verification process ID and allergy bands NPO status Completed bowel and skin preparation H&P and labs in chart Required forms complete Baseline VS and PA Valuables Voiding before surgery Pre-operative medications Final check with transport

1.2. Intra-Operative Phase

1.2.1. Surgical nursing Circulating nurse Set up the OR Ensures surgical team Maintains asepsis Communicates & documents "Scrub" nurse or tech Sets up field and tables Prepares equipment Assists surgeon and circulator (count) Labels specimens >> circulator >> lab Perioperative nurse

1.2.2. Surgical asepsis Three OR zones Unrestricted Semi-restricted Restricted Basics Only sterile touches wound or field Gown is sterile at level of field Top of draped tables only! Sterile >> sterile (or unsterile >> unsterile) Cannot contaminate field while moving around Prepare the field as close to time of surgery as possible Site prep At home Before the surgery

1.2.3. Health hazards Faulty or improper use of equipment Exposure to toxins Lasers Warning signs Goggles to prevent inhalation Smoke evacuators Blood and body fluids Sharps Bony fragments Special gear required

1.2.4. Adverse effects Allergic reactions Drug toxicity System alterations Dysrhythmias CNS changes hTN Thrombosis Trauma Larynx Mouth Nerves Skin

1.2.5. Anesthesia Selection criteria Medical history Type and duration of surgery Safety issues (airway) Emergency* Pain management Client's position Types General Regional Moderate MAC Local

1.2.6. Complications N/V Should pre-medicate Suctioning Anaphylaxis Medications, latex, etc. Can be fatal Hypoxia Variable causes Brain damage risk Hypothermia >98.0 (36.6) Many causes Lots of monitoring Malignant hyperthermia Pathophysiology Common cause: succinylcholine + INH Management Goals Manifestations Gerontological considerations Increased risk of complications Risk factors

1.2.7. Nursing interventions Anxiety Latex exposure Positioning injuries Patient's risk factors Common systems affected Long procedure Staff's knowledge Complications Prevention Interventions Protecting from injury ID bands Informed consent Verification of records Diagnostics Allergies Environmental monitoring Safety measures Blood products "Time-out" verification Advocacy Complications

1.2.8. Nursing responsibilities Transport to the OR Assisting anesthetist Monitoring devices

1.2.9. Skin closures Hold wound edges together For healing Occludes blood vessels Prevents contaminatin Various types Sutures/staples Tape or steri-strips Glue (dermabond)

1.3. Post-Operative Phase

1.3.1. Begins with PACU admission Recovery area Care in surgical unit Home Clinic follow-up

1.3.2. PACU nursing Care until patient has recovered from anesthesia Motor, sensory function Oriented Stable VS No signs of hemorrhage or complications Requires frequent skilled assessment Three phases Responsibilities Review of data prior to admission Focused assessment Proper positioning Airway maintenance Monitor for complications Targeted assessment for complications

1.3.3. Surgical dressings Purposes Healing Absorption Splint/immobilization Protection Homeostasis Comfort Management DOS >> POD #1 1st dressing change

1.3.4. Collaborative problems Pulmonary infection Hypoxia DVT Hematoma/hemorrhage Pulmonary embolism Wound dehisence Apply sterile or NS dressing Call the surgeon Wound evisceration Open with protrusion Immediate surgery!

1.3.5. Wound complications Impaired healing Chronic disease Elderly Increased sepsis Malnourished Immunosuppressed Prolonged stay Fluid accumulation Impaired healing Increased risk of infection Gerontological considerations Greater risk for complications Careful, frequent monitoring Confusion, delirium likely Watch drug dosages Hydration status Reorient PRN

1.3.6. Discharge for PACU Occurs when criteria met Stable BP Good RR Good O2 sat Modified Aldrete Score Transfer of care PACU >> Unit RN Give a good report Direct discharge instructions Planning and assessment Shorter stays = less teaching time Written, verbal instructions

2. Diabetes

2.1. Overview

2.1.1. Characterized by hyperglycemia Insulin secretion defect Insulin action defect BOTH

2.1.2. Demographics 23 million Americans 1/3 are undiagnosed +1 mil per year Increasing Certain populations Minorities Elderly

2.2. Risk Factors

2.2.1. Obesity

2.2.2. Impaired FG or GT Pre-diabetes Glucose b/w normal and diabetic levels

2.2.3. HTN

2.2.4. Dyslipidemia Low HDL (35 and below) High TG (250 and higher)

2.2.5. Gestational diabetes

2.2.6. High birth weight delivery (>9 lbs)

2.2.7. Metabolic syndrome Picture of patient with Type 2 DM Diagnosed with 3+ criteria Insulin resistence Central obesity Dyslipidemia High BP (>130/85) Pro-inflammatory state Pro-thrombotic state

2.2.8. Personal characteristics Family history (parents or siblings) Race or ethnicity Age 45+ yo Age-related glucose elevation

2.3. Diagnostic Criteria

2.3.1. Normal FPG <100 mg/dL 2 hr. PG <140 mg/dL

2.3.2. Pre-diabetes FPG 100-126 m/dL 2 hr. PG 140-199 mg/dL

2.3.3. Diabetes FPG 126+ mg/dL RPG 200+ plus symptoms 2 hr. PG 200+

2.4. Classifications

2.4.1. Type I DM Autoimmune process destroys beta cells Insulin-dependent r/t altered production Acute onset before age 30 5-10% of persons with DM

2.4.2. Type II DM Pathophysiology Insulin resistance + impaired beta cell function >> Decreased insulin production Slow, progressive glucose intolerance 90-95% of DM cases Onset age 30+ and obese Treatment Diet and exercise first Oral hypoglycemics, insulin Insulin Functions Transports and metabolizes glucose >> energy Stimulates glucose storage in liver and muscle as glycogen Signals liver to stop glucose release Enhances storage of fat into adipose tissue Accelerates transport of amino acids into cells Inhibits breakdown of stored glucose, protein, fat Manifestations Polyuria, polydipsia, polyphagia Fatigue, weakness Vision changes Parasthesias Dry skin Slow healing Recurrent infections Diagnostics FBG 126 mg/dL + RG >200 mg/dL

2.4.3. Gestational

2.4.4. Associational

2.5. Treatment

2.5.1. Goals of treatment Normalize blood levels Intensive methods = best outcome Fewer vascular, neuropathic complications Dietary management Goals Role of the nurse Meal planning Glycemic index Other concerns Exercise regimen Lowers glucose, weight, CV risk Certain precautions apply Need regular daily exercise Recommended stress test Gerontological considerations

2.5.2. Aspects of treatment Oral agents Supplemental for Type 2 DM May combine agents Most CSE: Hypoglycemia Patient education Process Insulin therapy Requires blood glucose monitoring Various categories and durations Usually injected, but may be inhaled Sick day management Use meds as prescribed Test blood, urine q3-4 hours Report elevations to HCP Supplemental insulin Substitute soft meals PRN

2.6. Complications

2.6.1. Acute events Hypoglycemia Very low glucose (<60 mg/dL) Causes Manifestations Assessment Management DKA (Type 1) HHNS The initialism Lack of effective insulin causes hyper- states Minimal to no ketosis Results of hyperglycemia Manifestations Treatment Prevention

2.6.2. Chronic problems Macrovascular Advanced atherosclerosis CAD, CVD, PVD Microvascular Retinopathy Nephropathy Neuropathic Peripheral neuropathy Autonomic neuropathy Hypoglycemic unawareness Neuropathy Sexual dysfunction

2.7. Nursing Process

2.7.1. Assessment Presenting problem Related needs Patient knowledge Blood glucose Skin Preventative measures

2.7.2. Diagnoses Deficient knowledge Anxiety Fluid/electrolyte imbalance Fluid volume deficit

2.7.3. Collaboration

2.7.4. Planning, goals

2.7.5. Interventions

2.7.6. Evaluation Fluid-electrolyte balance Knowledge re: HHNS No complications

3. HIV

3.1. CDC Statistics

3.1.1. 1.14 million HIV cases in 2009 US statistics 18% are undiagnosed

3.1.2. 57, 000 new cases in 2006

3.1.3. Concentrated in urban areas

3.1.4. Highest levels in the South

3.2. Transmission

3.2.1. HIV or infected CD4 lymphocytes

3.2.2. Non-casual contact

3.2.3. Increased risk with broken skin

3.2.4. Fewer blood transfusions infected Since 1985 screening Still possible during "window period"

3.3. Risk Factors

3.3.1. Risk factors Sharing used needles Sexual contact Blood products before 1985 Congenital factors

3.3.2. Gerontology Lack of condom use Not viewed as high-risk IV drug users Transfusions before 1985 Reduced immunity

3.4. Prevention

3.4.1. Safe sex practices

3.4.2. Clean needles

3.4.3. Blood screening

3.4.4. Education for childbearing women

3.5. HCP Information

3.5.1. Standard precautions apply

3.5.2. Post-exposure protocol per institution

3.6. Stages

3.6.1. Primary infection CDC Category A Acute infection Window period (lack the antibodies) Rapid viral replication & spread Teetering on viral setpoint No symptoms to flu-like symptoms

3.6.2. Asymptomatic CDC Category A Hit viral set point >> chronic stage >500 CD4/mm3 Sufficient immunity

3.6.3. Symptomatic CDC category B from that point on 200-499 CD4/mm3 Gradual decline in T-cells Develop symptoms r/t non-category C conditions

3.6.4. AIDS CDC category C CD4 <200/mm3 Immunity seriously compromised Develop associated conditions

3.7. Management

3.7.1. Assessment Health history (risk factors) S/S immunosuppression

3.7.2. Diagnostics HIV antibody tests (EIA) Positive Negative Testing types Education, counseling Viral load tests RT-PCR NASBA Viral load test HIV culture

3.7.3. Treatment Meds determined by T-cell count <350 cells/mm3 Viral load >100K copies per mL Antiviral agents NRTIs NNRTIs Protease inhibitor Fusion inhibitor Integrase strand transfer inhibitor Multiclass combo products Other considerations Viral load Severity of HIV/AIDS Related symptoms Adherence Drug resistance Monotherapy Adherence Late initiation Goals Suppress viral load Preserve immunity QOL; prevent M&M

3.8. Associated Diseases

3.8.1. Respiratory Pneumocystis pneumonia Most common infection Manifestations Diagnosed by lung/bronchial secretions Treatment Mycobacterium avium complex (MAC) Common, opportunistic RR, GI, lymph nodes, bone marrow Increases mortality rate Treatment Tuberculosis (TB) Lungs, CNS, bone, pericardium, stomach Peritoneum, scrotum Depends on adherence to antiretroviral therapy

3.8.2. Oral candidasis Fungal infection Creamy white patches in oral cavity Moves to stomach, esophagus if untreated Impacts nutritional status Problems swallowing Retrosternal pain Oral lesions

3.8.3. Oncologic Kaposi's sarcoma Most common related malignancy More common in males who are GB Manifestations Confirmed by biopsy Treatment Variable prognosis B-cell lymphomas 2nd most common malignancy Higher grade, aggressive, resistent Outside of the lymph nodes Multi-organ involvement Unsuccesful treatment

3.8.4. Neurologic Distal sensory polyneuropathy Distal symmetric polyneuropathy (DSPN) Most common Advanced HIV Result of process Pain, impaired function HIV encephalopathy AIDS dementia Progressive decline Subtle indications Tough to confirm Cryptococcus neoformans Opportunistic fungal infection Diagnosed by CSF Manifestations Progressive multifocal leukoencephalopathy Demyelinating disorder Manifestations Others Toxoplasma gondii CMV Mycobacterium TB Vasculas myelopathy

4. Endocrine Disorders

4.1. Overview

4.1.1. Hormones Messengers, regulators Made and released by glands Integrate with nervous system

4.1.2. Functions of endocrine system Differentiation of reproductive and CNS Stimulating growth/development Coordiating male/female reproductive systems Maintaining homeostasis Correction and adaptation

4.1.3. General characteristics Rate and rhythm Within feedback system Act only on specific target cells Constantly made by kidneys or deactivated by liver, etc Released in response to alteration Designed to maintain certain levels Regulated by several types of factors

4.2. Feedback Systems

4.2.1. To maintain homeostasis

4.2.2. Two types Negative Most common (Erythropoietin regulates erythropoesis) Process Positive Social network Oxytocin release during labor

4.2.3. Hypothalamus-Pituitary System Hypothalamus hormones TRH GnRH GFR CRH Pituitary hormones Posterior (oxytocin and ADH) Anterior (adenohypophysis)

4.3. Thyroid Disorders

4.3.1. Thyroid hormone functions Metabolic activity controller T4 = weak T3 = strong gas pedal Brain development Normal growth All organ systems

4.3.2. Specific tests TSH Diagnosis, monitoring replacement Differentiates b/w thyroid, pituitary, or hypothalamic disorders Serum free T4 To confirm abnormal TSH Measures active T4 Serum free T3/T4 Total of protein-bound levels In response to TSH Others Thryoid antibodies Radioactive iodine uptake

4.3.3. Alterations Hypothyroidism Suboptimal TH levels Affects all function Mild, subclinical forms to myxedema Increases with age Most common cause: autoimmune thyroiditis (Hashimoto) Manifestations Treatment Care plan Hyperthyroidism Graves disease Characteristics Assessment/diagnosis Gerontological considerations Thyrotoxic crisis

4.4. Parathyroid Disorders

4.4.1. Produces PTH Most important factor in regulating Ca Increased Ca and decreased P Stimulated by hypocalcemia >> PTH >> Kidneys >> Increased Ca resabsorption (decreased P) >> Rising Ca >> Inhibited PTH Role of active Vitamin D Promotes reabsorption of Ca and P in gut Increases Ca while decreasing PTH Promotes bone mineralization

4.4.2. Alterations Hyperparathyroidism Bone decalcification & kidney stones Can be secondary to CRF Manifestations Assessment/diagnostics Medical management Hypercalcemic crisis Hypoparathyroidism Usually caused by decreased PTH post-op Progresses to Manifestations Assessment Treatment

4.5. Adrenal Disorders

4.5.1. Parts of the gland Cortex (outer) Glomerulosa (aldosterone) Fasiculata (GC: CCC) Reticularis Medulla (inner) Catecholamines E and NE

4.5.2. Adrenocortical insufficiency Addison disease Inadequate adrenal function Need corticosteroids Daily for 2-4 weeks Can suppress function of glands Manifestations Weakness, anorexia, GI s/s Fatigue, emaciation Dark pigmentation on bony prominences hTN, low Na and glucose High K Mental changes Dehydration r/t EI Addisonian crisis Disease progression and acute hTN Cyanosis and shock symptoms Diagnostics Treatment Nursing care

4.5.3. Cushing syndrome Excess activity Often caused by corticosteroids Or hyperplasia Or malignant bronchogenic carcinoma Ineffective normal feedback Loss of usual diurnal pattern Manifestations Too much GC and androgens (+MC) Central obesity "Buffalo-hump" Moon face Heavy trunk Thin skin Weakness Muscle wasting, osteoporosis HTN r/t Na-water retention Slow healing Assessment/diagnosis Dextramethasone suppression test 24 hour urine free cortisol Plasma ACTH; US, MRI, CV (tumors) Medical management By cause Pituitary tumor Adrenal tumor Corticosteroids

4.6. Gerontological Concerns

4.6.1. Thyroid gland Atrophies with age Decrease TSH, T3, T4 >> Hypothyroidism Usually maintain adequate function

4.6.2. Parathyroid glands Increased basal PTH + secretion = More Ca resorption, hypercalcemia, hypercalciuria

4.6.3. Adrenal cortex Fibrotic, shrinks Higher cortisol levels Decreased levels of androgens, aldosterone Possible decrease response r/t >> Na restriction + upright posture