Log book for students Topics and Common Drugs Manual€¦ · Log book for students Topics and Common Drugs Manual Common Blood Investigations (Adult) Determinations Reference range

Prince Sattam Bin Abdulaziz University College of Applied Medical Sciences

Department of Nursing

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Adult and Geriatric Health Nursing-1 / Clinical (NRSG 244)

Log book for students

Topics and Common Drugs Manual

Common Blood Investigations (Adult)

Determinations

Reference range

Clinical Significance Conventional Unit SI Unit

Complete Blood Count

Red Cell Count Males: 4,600,000–

6,200,000/cu mm

Females: 4,200,000–

5,400,000/cu mm

Males: 4.6–6.2 x1012/L

Females: 4.2–5.4 x1012/L

Increased in severe diarrhea and dehydration,

polycythemia, acute poisoning, pulmonary

fibrosis

Decreased in all anemias, in leukemia, and

after hemorrhage when blood volume has

been restored

Hemoglobin Males: 14–17 gm/dL

Females:12–16 gm/dL

140-170 g/L

120-160 g/L

Increased in polycythemia, chronic

obstructive pulmonary disease, failure of

oxygenation because of congestive heart

failure, and normally in people living at high

altitudes

Decreased in various anemias, pregnancy,

severe or prolonged hemorrhage, and with

excessive fluid intake

Hematocrit Male: 40 – 54%

Female: 37- 47%

0.40 – 0.54

0.37 – 0.47

Increased in dehydration, pulmonary fibrosis,

and polycythemia.

Decreased in bleeding, sickle cell anemia,

bone marrow suppression, and

overhydration.

Platelet Count 150,000-400,000/mm3

150-400 x 109/L Increased in malignancy, myeloproliferative

disease, rheumatoid arthritis, and

postoperatively; about 50% of patients with

unexpected increase of platelet count will be

found to have a malignancy

Decreased in thrombocytopenic purpura,

acute leukemia, aplastic anemia, and during

cancer chemotherapy

White Cell Count Total: 3,500–

12,000/cu mm

3.5–12 x109/L

Neutrophils 3000-5800/mm3 3000-5800 x 106/L Neutrophils increased with acute infections,

trauma or surgery, leukemia, malignant

disease, necrosis; decreased with viral

infections, bone marrow suppression, and

primary bone marrow disease

Lymphocytes 1500-3000/mm3 1500-3000 x 106/L Lymphocytes increased with infectious

mononucleosis, viral and some bacterial

infections, hepatitis; decreased with aplastic

anemia, SLE, and immunodeficiency

including AIDS



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Monocytes 300-500/mm3 300-500 x 106/L Monocytes increased with viral infections,

parasitic disease, collagen and hemolytic

disorders; decreased with use of

corticosteroids, RA, and HIV infection

Eosinophils 50-250/mm3 50-250 x 106/L Eosinophils increased in allergy, parasitic

disease, collagen disease, subacute

infections; decreased with stress, and use of

some medications (ACTH, epinephrine,

thyroxine)

Basophils 15- 50/mm3 15- 50 x 106/L Basophils increased with acute leukemia and

following surgery or trauma; decreased with

allergic reactions, stress, allergy, parasitic

disease, and use of corticosteroids

Determinations

Reference range


Coagulation Profile

Prothrombin Time (PT) 9 –12 sec 9 –12 sec Prolonged by deficiency of factors I, II, V,

VII, and X, fat malabsorption, severe liver

disease, and coumarin anticoagulant therapy

INR 0.9-1.1

2–3 for therapy in atrial

fibrillation, deep vein

thrombosis, and

pulmonary embolism

2.5–3.5 for therapy in

prosthetic heart valves

0.9-1.1

INR used to standardize the prothrombin

time and anticoagulation therapy

Activated Partial

Thromboplastin Time

(APTT)

25–40 sec

25–40 sec

Prolonged in deficiency of fibrinogen, factors

II, V, VIII, IX, X, XI, and XII, and in heparin

therapy

Electrolytes

Chloride 96–106 mEq/L 96–106 mmol/L Increased in nephrosis, nephritis, urinary

obstruction, cardiac decompensation, and

anemia

Decreased in Diabetes mellitus, Diarrhea,

Vomiting, Pneumonia, Heavy metal

poisoning, Cushing’s syndrome, Intestinal

obstruction, and Febrile conditions

Potassium 3.5–5.1 mEq/L 3.5–5.1 mmol/L Increased in renal failure, acidosis, cell lysis,

tissue breakdown or hemolysis

Decreased in hyperparathyroidism, vitamin

D deficiency, GI losses, and diuretic

administration

Sodium 135–145 mEq/L 135–145 mmol/L Increased in hemoconcentration, nephritis,

and pyloric obstruction

Decreased in alkali deficit, Addison’s

disease, and myxedema.



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Determinations

Reference range


Liver Function Test

Aspartate

Aminotransferase (AST)

5-35 mU/mL 5-35 IU/L Increased in myocardial infarction, Skeletal

muscle disease, and liver disease

Alanine

Aminotransferase (ALT)

7- 40 mU/mL 7- 40 IU/L Same conditions as AST but increase is more

marked in liver disease than AST

Albumin

3.5-5.0 g/dL

35-50 g/L Increased in hemoconcentration and shock

Decreased in malnutrition, hemorrhage, loss

of plasma from burns, and proteinuria

Alkaline Phosphatase 50–120 UL 50–120 UL Increased in conditions reflecting increased

osteoblastic activity of bone

Rickets

Hyperparathyroidism

Hepatic disease

Bone disease

Bilirubin, Total 0.3–1.0 mg/dL 5–17 μmol/L Increased in biliary obstruction and disease,

hepatocellular damage (hepatitis), Pernicious

anemia, and hemolytic disease of newborn

Protein, Total

6–8 gm/dL 60–80 g/L Increased in hemoconcentration and shock

Decreased in malnutrition, hemorrhage, loss

of plasma from burns, and proteinuria

Renal Function Test

Creatinine

0.6-1.2 mg/dL

50-110 μmol/L Increased in nephritis, and chronic renal

disease

Urea 10–20 mg/dL 3.6–7.2 mmol/L Increased in obstructive uropathy, mercury

poisoning, and nephrotic syndrome

Decreased in pregnancy

Bone Profile

Calcium (Total) 8.4–10.6 mg/dL 2.10–2.50 mmol/L Incread in tumor or hyperplasia of

parathyroid, hypervitaminosis D, multiple

myeloma, nephritis with uremia, malignant

tumors, sarcoidosis, hypoparathyroidism,

skeletal immobilization, and excess calcium

intake: milk alkali syndrome

Decreased in hyperthyroidism, diarrhea,

celiac disease, vitamin D deficiency, acute

pancreatitis, nephrosis, and after

parathyroidectomy

Phosphate 3 –4.5 mg/dL 1.0–1.5 mmol/L Increased in chronic nephritis, and

hypoparathyroidism



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Determinations

Reference range


Immunologic Markers

C-Reactive Protein 1mg/dL (<10 mg/L) An increase indicates active inflammation

Erythrocyte

sedimentation Rate (ESR)

Males under 50 yr: <15

mm/h

Males over 50 yr: <20

mm/h

Females under 50 yr:

<25 mm/h

Females over 50 yr:

<30 mm/h

<15 mm/h

<20 mm/h

<25 mm/h

<30 mm/h

Increased in tissue destruction, whether

inflammatory or degenerative; during

menstruation and pregnancy; and in acute

febrile diseases

Cardiac Markers

Troponin I < 0.35 ng/mL < 0.35 μg/L Increased in myocardial infarction

Creatine kinase (CKMB) MB band absent MB band increased in myocardial infarction,

and ischemia

Lactate Dehydrogenase 90–176 mU/m 90–176 U/L Increased in untreated pernicious anemia,

myocardial infarction, pulmonary infarction,

and liver disease

Thyroid Function Test

Free Thyroxine (Free T4) 0.8–2.7 ng/dL 10.3–35 pmol/L Increased in euthyroid patients with normal

free thyroxine levels may have abnormal T3

and T4 levels caused by drug preparations

Thyroid Stimulating

hormone (TSH)

0.4–4.2 mIU/L Increased in hypothyroidism

Decreased in hyperthyroidism

T3 total circulating—RIA 70–204 ng/dL 1.08–3.14 nmol/L

3.8 – 6.0 pmol/L

Increased in Pregnancy and Hyperthyroidism

Decreased in Hypothyroidism

Glucose Profile

Glycosylated

Hemoglobin (also called

Hemoglobin A1C and

HbA1c)

4.4%–6.4% Increased in suboptimal glucose control

Glucose, fasting 60–110 mg/dL 3.3–6.05 mmol/L Increased in diabetes mellitus, nephritis,

hypothyroidism, early hyperpituitarism,

cerebral lesions, pregnancy, and uremia

Decreased in hyperinsulinism,

hyperthyroidism, late hyperpituitarism,

pernicious vomiting, Addison’s disease, and

extensive hepatic damage



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Determinations

Reference range


Lipid Profile

Cholesterol, Total

150–200 mg/dL 3.9–5.2 mmol/L Increased in lipemia, obstructive jaundice,

diabetes, and hyperthyroidism

Decreased in pernicious anemia, hemolytic

anemia, hypothyroidism, and severe

infection terminal states of debilitating

disease

Cholesterol, HDL Males: 35–70 mg/dL

Females: 35 –85

mg/dL

Males: 0.91–1.81

mmol/L

Females: 0.91–2.20

mmol/L

HDL cholesterol is lower in patients with

increased risk for coronary heart disease

Cholesterol, LDL mg/dL desirable levels:

< 160 if no coronary

artery disease (CAD)

and< 2 risk factors

< 130 if no CAD and 2

or more risk factors

< 100 if CAD present

LDL cholesterol is higher in patients with

increased risk for coronary heart disease

Triglycerides 100–200 mg/dL 1.13–3.8 mmol/L When increased, increases risk for

atherosclerosis

Blood Gas Analysis

Partial Pressure of

Oxygen

80–100 mm Hg 10.67 – 13.33 kPa Increased in polycythemia

Decreased in anemia and cardiac or

pulmonary disease

Partial Pressure of Carbon

Dioxide

35–45 mm Hg 4.67 – 6.00 kPa Increased in respiratory acidosis and

metabolic alkalosis

Decreased in respiratory alkalosis and

metabolic acidosis

pH 7.35–7.45 7.35–7.45 Increased in vomiting, hyperventilation,

fever, and intestinal obstruction

Decreased in uremia, diabetic ketoacidosis,

hemorrhage, and nephritis

Bicarbonate 22 - 26 mEq/L 22 - 26 mmol/L Increased in metabolic alkalosis, and

respiratory acidosis

Decreased in metabolic acidosis and

respiratory alkalosis

O2 saturation > 95% > 95% Increased in central nervous system oxygen

toxicity. Decreased in Hypoxia, conditions

that can cause hypoxia include: Lung

diseases such as chronic obstructive

pulmonary disease (COPD), emphysema,

bronchitis, pneumonia, and pulmonary

edema.



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Respiratory Care Modalities Incentive Spirometry

Mechanism of Action Device that provides visual feedback to encourage the patient to inhale slowly and deeply to maximize lung inflation and prevent atelectasis Types: Volume type / Flow type

Indications Thoracic surgeries

Abdominal surgeries

Nursing Management Positioning the patient properly (semi Fowlers or high Fowlers)

Teaching the technique of using the device

Setting realistic goals

Recording the result of the therapy

Proper cleaning and storage

Nebulizer Therapy Mechanism of Action Apparatus disperses the moisturizing agent or medication like bronchodilators and

mucolytic into microscopic particles and delivers it to the lungs as patient inhales

Indications Difficulty in clearing respiratory secretions

Reduced vital capacity with ineffective breathing and coughing.

Delivering aerosol

For lung expansion in COPD patients

Nursing Management Position in semi Fowlers

Patient instructed to deep breath

Encourage the patient to cough and monitor the effectiveness of the therapy

Make sure mist appears when functioning

For COPD patients use air instead of oxygen

Ensure connections are secure

Proper cleaning and storage

Chest Physiotherapy: Postural Drainage Mechanism of Action Several positions are used so that the force of gravity helps move secretions from

smaller bronchial airways to the main bronchi and trachea

Indications Remove bronchial secretions

Improve ventilation

Increase efficiency of the respiratory muscle

Nursing Management Should be aware of the diagnosis and lung segment involved

Auscultate chest before and after the procedure

Administer bronchodilators and mucolytic before the procedure

Position the patient comfortably with pillows to drain lower lobes followed by upper lobes

Should be performed two to four times before a meal

Patient to remain in each position for 10-15 minutes

Explain to breathe in through the nose and breathe out through pursed lip

Explain how to cough and remove secretions .suction if needed

After procedure note amount, color, viscosity if foul smelling and document

Give mouth wash after the procedure

Notify physician if any abnormality noted



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Chest Physiotherapy: Chest Percussion

Mechanism of Action Carried out by cupping the hands and lightly striking the chest wall in a rhythmic fashion over lung segments to be drained. Wrists alternately flexed and extended

Indications Helps dislodge mucus adhering to the bronchioles and bronchi

Nursing Management Ensure patient is not wearing any constrictive clothing, not eaten and administered pain medication

Place a soft cloth or towel over segment of chest being cupped to prevent skin irritation and redness

Avoid over chest drainage tubes, spine, liver and kidneys

Encourage diaphragmatic breathing

Chest Physiotherapy: Vibration

Mechanism of Action It Is a technique of applying manual compression and tremor to the chest wall during exhalation phase

Indications Increases the velocity of air expired from smaller airways thus freeing the mucus

Nursing Management Evaluate breath sounds before and after the procedure

After three four vibrations patient encouraged to cough contracting the abdominal muscles

Percussion alternating vibration is performed to 3-5 minutes for each position

Stop procedure if increased pin, shortness of breath, lightheadedness and hemoptysis



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Non-Invasive Ventilation

Mechanism of Action Method of positive pressure ventilation given via face-mask that covers nose and mouth. The leak proof mask keeps the alveoli open and prevents respiratory failure and improves tissue oxygenation

Indications Acute or chronic respiratory failure

Acute pulmonary edema

COPD

Chronic heart failure

Sleep apnea

Nursing Management Monitor vital signs

Ensure that the mask is leak proof

Do not use on patients with respiratory failure and dysrhythmias

Chest Drainage

Mechanism of Action Thoracostomy creates an opening in the chest wall through which a chest tube is

placed. Chest tube is attached to a drainage device Allows air and fluid to leave the chest Contains a one-way valve to prevent air and fluid returning to the chest Designed so that the device is below the level of the chest tube for gravity drainage

Indications Pneumothorax

Hemothorax

Pleural effusion

Tension pneumothorax

After thoracic surgery

Nursing Management Keep the tubing coiled on the bed near the patient

Record drainage on flow sheet

Change dressing according to unit protocol

Splint the incision site to facilitate coughing and deep breathing

Ensure that drainage flows into the drainage system by facilitating gravity drainage

If patient must be transported, disconnect from suction and keep drainage system upright below the level of the chest. do not clamp the tube

Chest x-ray studies are done daily



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AMLODIPINE

Action It prevents the passage of calcium ions across the myocardial cell membrane and vascular smooth muscle cells. This leads to dilation of coronary and peripheral arteries, and it decreases the force of the heart’s contraction and reduces the workload of the heart.

Uses Chronic stable angina pectoris, and hypertension

Side Effects Headache, dizziness, peripheral edema, bradycardia, hypotension

Nursing Considerations Assess Cardiac status (BP, pulse) I/O chart Administer Once daily, without regard to meals Evaluate Therapeutic response (decreases anginal pain / BP; increases exercise tolerance) Teach Patient / Family Not to double or skip dose To avoid hazardous activities / to change positions slowly To notify prescriber of irregular heartbeat, pulse <50 bpm, SOB, swelling of face, feet and hands, severe dizziness, constipation, nausea, hypotension



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CARVEDILOL

Action It has a mixture of α/β adrenergic blocking activity, thus it causes dilation of peripheral vessels, and a decrease in (1) peripheral vascular resistance, (2) CO, and (3) exercise induced tachycardia.

Uses Essential hypertension, CHF, LV dysfunction, cardiomyopathy

Side Effects Dizziness, bradycardia, postural hypotension, CHF pulmonary edema, diarrhea, impotence, thrombocytopenia, hyperglycemia, bronchospasm

Nursing Considerations Assess Renal & hepatic studies before initiating treatment I/O chart, daily weight Cardiac status (BP, pulse) Edema Administer DO NOT administer if pulse < 50bpm Before meals Evaluate Therapeutic response (decreases BP) Teach Patient / Family To comply with dosage schedule, even if feeling better To avoid hazardous activities / to change positions slowly To notify prescriber of pulse <50bpm, dizziness, confusion, depression, fever, weight gain, SOB, bleeding or bruising is noticed Not to discontinue product abruptly, taper over 1-2 weeks

LISINOPRIL

Action It prevents the conversion of angiotensin I to angiotensin II, leading to (1) reduction in angiotensin II, and (2) arterioles dilatation, and (3) reduction in peripheral vascular resistance.

Uses Mild to moderate hypertension, adjunctive therapy of systolic CHF, acute MI

Side Effects Vertigo, stroke, fatigue, hepatic failure, hepatic necrosis, proteinuria, renal insufficiency, angioedema

Nursing Considerations Assess Renal and hepatic studies before initiating treatment Cardiac status (BP, pulse) Administer Warn client that severe hypotension may occur after 1st dose of this medication Evaluate Therapeutic response (decreases BP / CHF symptoms) Teach Patient / Family To change positions slowly Not to discontinue product abruptly, taper over 1-2 weeks To avoid increasing potassium in diet



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ASPIRIN

Action It blocks pain impulses in the central nervous system, reduces inflammation by inhibition of prostaglandin synthesis. Its antipyretic action results from vasodilation of peripheral vessels. It decreases platelet aggregation.

Uses Mild to moderate pain or fever, post MI, prophylaxis of MI, Ischemic stroke, angina

Side Effects Nausea, vomiting, GI bleeding, tinnitus, hearing loss, thrombocytopenia, increase in PT, APTT and bleeding time, rash

Nursing Considerations Assess Pain / fever / blood studies Administer With food / milk to decrease gastric symptoms Teach Patient / Family To report symptoms of hepatotoxicity, ototoxicity, allergy reactions, bleeding To avoid alcohol consumption, GI bleeding may occur To discard tabs if vinegar like smell is detected

DIGOXIN

Action It inhibits the Na-K ATPase leading to an increase in the availability of calcium for contractile proteins, which causes (a) increase in cardiac output and (b) decrease in heart rate.

Uses Heart failure, atrial fibrillation, atrial flutter, cardiogenic shock

Side Effects Headache, dysrhythmias, hypotension, bradycardia

Nursing Considerations Assess Apical pulse for 1 minute before giving drug; if pulse < 60 in adult or < 90 in a infant, do not administer medication; notify prescriber Monitor drug levels (0.5-2 ng/ml) Administer Do not break, crush or chew caps Drug on 5 days in a week Perform / Provide Storage protected from light Teach Patient / family Not to stop drug abruptly Do not take antacid at the same time To notify prescriber of loss of appetite, lower stomach pain, diarrhea, weakness, drowsiness, headache, blurred vision, rash, depression, toxicity



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ISOSORBIDE DINITRATE

Action It causes relaxation of the vascular smooth muscles, thus decreases pre-load, after-load. It decreases (1) left ventricular end-diastolic pressure, (2) systemic vascular resistance, and (3) cardiac O2 demand.

Uses Treatment, prevention of chronic stable angina, angina pectoris

Side Effects Vascular headache, flushing, dizziness, postural hypotension

Nursing Considerations Assess Pain, BP, pulse Administer PO on empty stomach SL tabs to be placed under the tongue until dissolved Evaluate Decrease or prevention of anginal pain Teach Patient / Family To leave tabs in original containers That drug may cause headache That drug may be taken before stressful activity That SL may sting when drugs come in contact with mucous membranes To make position changes slowly, to prevent orthostatic hypotension To avoid hazardous activities if dizziness occurs

SALBUTAMOL

Action It acts on β2 receptors and increases levels of cAMP. This causes (1) relaxation in smooth muscles, (2) bronchodilation, (3) CNS / Cardiac stimulation, (4) diuresis, and (5) increase in gastric acid secretion.

Uses Acute bronchospasm, reversible airway obstruction, chronic respiratory conditions

Side Effects Tremors, anxiety, restlessness, palpitations, dry nose / throat

Nursing Considerations Assess Respiratory function Patient’s ability to self-medicate Administer Through nebulizer after diluting with 2.5ml of 0.9% of NaCl Sips of water for dry mouth Evaluate Therapeutic response (absence of dyspnea, wheezing, improved ABGs) Teach patient / Family To use exactly as prescribed To avoid smoking / persons with respiratory infections That paradoxic bronchospasm may occur, to stop product immediately To limit caffeine products



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Diclofenac Sodium

Action It inhibits prostaglandin synthesis

Uses Acute , chronic pain, bone pain, myalgia and headache

Side Effects CHF, dysrhythmias, MI, stroke, laryngeal edema, jaundice, nephrotoxicity, dysuria, hematuria, oliguria, UTI, bronchospasm, anaphylaxis

Nursing Considerations Assess: Pain, Blood count, asthma, LFT Administer: Take 30 minutes before or 2 hours after meals. Teach Patient/Family: Avoid alcohol To report bleeding

Paracetamol

Action It inhibits prostaglandin synthesis

Uses Pain, fever, headache, osteoarthritis

Side Effects GI bleeding, hepatotoxicity, renal failure

Nursing Considerations Assess: Hepatic studies, Renal studies, other blood studies, I&O Administer: With food or milk Teach Patient/Family: Not to use with alcohol.

Therapeutic Communication

Communication is the interchange of information between two or more people. It is a process that has two main purposes: to influence others and to gain information.

Therapeutic communication promotes understanding and can help establish a constructive relationship between the nurse and the client.

Therapeutic communication techniques facilitate communication and focus on the client’s concerns (goal-directed).

Nurses need to respond not only to the content of a client’s verbal message but also to the feelings expressed.



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Pain Management

Definition:

It is an unpleasant sensory and emotional experience with actual or potential tissue damage.

It is whatever a person says it is, existing whenever the experiencing person says it does. Types of Pain:

Acute pain

Chronic (persistent) pain

Cancer-related pain

Note: Pain may also be classified by location or etiology

Effects of Pain:

Sleep deprivation

Acute pain o Can affect respiratory, cardiovascular, endocrine, and immune systems. o Stress response increases metabolic rate and cardiac output, and increases risk for

physiologic disorders

Chronic pain o Depression o Increased disability o Suppression of immune function

Factors that Influence Pain:

Past experience

Anxiety

Depression

Culture

Gender

Genetics

Gerontologic considerations

Expectations Pain Assessment:

The patient’s pain goal or expectations of comfort and pain relief

Meaning of pain for the patient

Behaviors associated with the pain

Physiologic responses to the pain

Characteristics: intensity, timing, location, quality

Aggravating or alleviating factors Pain Intensity Scales:



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Faces Pain Scale

Pharmacologic Interventions:

Opioid analgesics act on the CNS to inhibit activity of ascending nocioceptive pathways.

NSAIDs decrease pain by inhibiting cyclo-oxygenase, which is the enzyme involved in the production of prostaglandin.

Local anesthetics block nerve conduction when applied to the nerve fibers. Nonpharmacologic Interventions:

Cutaneous stimulation, massage, and use of hot and cold may be explained by the gateway theory.

Use of heat and cold changes blood flow to the areas and promotes healing.

Use of distraction, relaxation, and guided imagery may redirect attention, promote muscle relaxation, and affect perception or reception of pain stimulus in the brain.



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Neurological and Neurosurgical Methods of Pain Relief:

Intrathecal and epidural catheters

TENS units

Interruption of pain pathways o Cordotomy o Rhizotomy

Adverse Effects of Narcotic Drugs:

Respiratory depression

Sedation

Nausea and vomiting

Constipation

Pruritus TRAMADOL

Action It binds to opioid receptors, thus inhibits reuptake of norepinephrine and serotonin. Does not cause histamine release or affect heart rate.

Uses Analgesic and pain killer

Side Effects Somnolence, dizziness, orthostatic hypotension, nausea, constipation, GI bleeding

Nursing Considerations Assess Pain, bowel pattern, CNS changes Administer With antiemetic for nausea, vomiting Perform / Provide Assistance with ambulation Safety measures: side rails, night light, call bell within reach Teach Patient / Family That drowsiness, dizziness and confusion may occur, to call for assistance To make position changes slowly, orthostatic hypotension may occur

MEFENAMIC ACID

Action It decreases inflammation, pain, and fever, probably through inhibition of cyclooxygenase activity and prostaglandin synthesis.

Uses For relief of mild to moderate pain in patients 14 years and older; treatment of primary dysmenorrhea.

Side Effects Hypertension, tachycardia, dizziness, headache, pruritus, rashes, abdominal pain, constipation, diarrhea, dyspepsia, flatulence, GI ulcers (gastric/duodenal), gross bleeding/perforation, heartburn, nausea, vomiting, elevated liver enzymes, abnormal renal function, edema, tinnitus.

Nursing Considerations Monitor Closely monitor BP during initiation and throughout the course of treatment. Monitor for signs and symptoms of GI bleeding. Teach Patient / Family Patients on long-term treatment should have their CBC and a chemistry profile checked periodically. Be cautious



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CV risk: NSAIDs may cause an increased risk of serious CV thrombotic events, MI, and stroke, which can be fatal.

GI risk: NSAIDs cause an increased risk of serious GI adverse events, including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal.

MORPHINE

Action Depresses pain impulse transmission at the spinal cord level by interacting with opioid receptor.

Uses It reliefs moderate to severe acute and chronic pain, dyspnea associated with acute left ventricular failure and pulmonary edema. It can be used for preoperative sedation, adjunct to anesthesia, and analgesia during labor.

Side Effects Hypotension, orthostatic hypotension, bradycardia, lightheadedness, dizziness, nausea, vomiting, constipation, respiratory depression, apnea, depression of cough reflex, urinary retention.

Nursing Considerations Assess Pain, bowel status, I&O, vital signs, CNS changes Administer Do not break, crush, or chew controlled pills. With antiemetic for nausea, vomiting. For treatment of overdose, Naloxone (Narcan) 0.2 to 0.8 mg IV, O2, IV fluids, vasopressors are used. Perform / Provide Assistance with ambulation Safety measures: side rails, night light, call bell within reach Gradual withdrawal after long-term use Teach Patient / Family To make position changes slowly, orthostatic hypotension may occur To know that withdrawal symptoms may occur: nausea, vomiting, cramps, fever, faintness, anorexia.

METOCLOPRAMIDE Action It is central dopamine receptor antagonist, which enhances response to acetylcholine

of tissue in the upper GI tract.

Uses It is commonly used to treat nausea and vomiting, to facilitate gastric emptying in people with gastroparesis, and as a treatment for the gastric stasis often associated with migraine headaches.

Side Effects Sedation, fatigue, restlessness, headache, sleeplessness, dry mouth, nausea, vomiting, constipation, neutropenia, leukopenia, agranulocytosis.

Nursing Considerations Assess Nausea, vomiting, anorexia, constipation, irritability Administer Half to one hour before meals, frequent rinsing of mouth for dry oral cavity. Perform / Provide Protect from light, discard open ampoules. Teach Patient / Family Avoid driving, alcohol other CNS depressants that will enhance sedating properties of this product.



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RANITIDINE

Action Blocks the production of acid by acid-producing cells in the stomach. It belongs to a class of drugs called H2 (histamine-2) blockers.

Uses To treat and prevent ulcers in the stomach and intestines.

Side Effects Headache, dizziness, tachycardia, blurred vision, constipation, abdominal pain, diarrhea, nausea, hepatotoxicity, hallucination (geriatric patients).

Nursing Considerations Assess Gastric pH, I&O ratio, creatinine, LFT, nausea, vomiting cramps Administer Antacids 1 hour before or 1 hour after ranitidine, no dilution needed for IM injection in large muscles. Should be diluted (in NaCl or D5W) if administered in IV route. Perform / Provide Storage in room temperature Teach Patient/ Family Avoid hazardous activities like driving, must be taken on prescribed time.

FOLIC ACID (Vitamin B9)

Action It is needed for erythropoiesis, it increases RBC, WBC, Platelet formation in megaloblastic anemias

Uses Megaloblastic or macrocytic anemia caused by folic acid deficiency, hepatic disease, alcoholism, hemolysis, intestinal obstruction pregnancy to reduce risk for neural tube defect.

Side Effects Flushing, bronchospasm, hypersensitivity reactions.

Nursing Considerations Assess Fatigue, dyspnea, weakness, hemoglobin, hematocrit. Administer IV route with most IV solutions Evaluate Therapeutic response Teach Patient / Family Compliance Increase high folic acid foods – organ meats, vegetables, fruits Urine will turn bright yellow Report allergic reactions



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PREDNISOLONE

Action Decreases inflammation by suppression of migration of polymorphonuclear leukocytes, fibroblasts, reversal to increase capillary permeability, and lysososmal stability, minimal mineralocorticoid activity.

Uses Severe inflammation, immunosuppression, neoplasms.

Side Effects Sore throat, headache, indigestion, increase in appetite and weight gain, increased thirst, raised blood pressure, tiredness, confusion, muscle weakness or muscle cramps, difficulty in sleeping

Nursing Considerations Assess Nausea, vomiting, anorexia, confusion, hypotension, weight loss before and during treatment. Administer For long term use alternate-day therapy is recommended to decrease adverse reaction, use lowest effective dose with food or milk to decrease GI symptoms. Perform / Provide Assistance with ambulation to patient with bone tissue disease to prevent fractures. Teach Patient/ family If therapeutic response decreases, dosage adjustment may be needed, avoid vaccinations.

CEFUROXIME Action It inhibits bacterial cell wall synthesis and renders cell wall osmotically unstable

leading to cell death.

Uses Surgical prophylaxis, for gram negative and gram positive organisms of serious lower respiratory tract infection, urinary tract infection, skin, bone, joint, gonococcal infections, septicemia, meningitis

Side Effects Dizziness, headache, fatigue, severe diarrhea (e.g., pneudomembranous colitis), nephrotoxicity, leukopenia

Nursing Considerations Assess Nephrotoxicity: increased BUN, Creatinine Bowel pattern daily, discontinue if severe diarrhea occurs Urine output, notify doctor if decreasing (nephrotoxicity) Administer Do not break, crush, or chew On an empty stomach 1 hour before or 2 hours after a meal For 10-14 days to ensure organism death With food if needed for GI symptoms After Culture & Sensitivity (C&S) Evaluate Therapeutic response (negative C&S) Teach patient / Family If diabetic, to use blood glucose testing To complete full course of therapy, to report persistence diarrhoea To use yogurt or buttermilk to maintain intestinal flora, decrease diarrhoea To notify prescriber if breastfeeding To report sore throat, bruising, bleeding, joint pain, diarrhoea with mucus, blood Treatment of anaphylaxis: epinephrine, antihistamines, resuscitate if needed.



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TAZOCIN

Action It interferes with the cell wall replication of the susceptible organism, which facilitates bursting of unstable cell wall (osmotic pressure).

Uses Moderate to severe infections (e.g., S. Aureus, resistant E. Coli)

Side Effects Nausea, vomiting, diarrhea, vaginitis, bone marrow depression, renal failure, sore throat, bruising, fever, fatigue

Nursing Considerations Assess For infection: temperature, stools, urine, sputum, wounds I&O ratio, report hematuria, oliguria Bowel pattern CBC and coagulation profile Allergies before initiation of therapy, reaction of each medication Administer IV after dilution Perform / Provide Epinephrine, suction, tracheostomy set, Endotracheal intubation equipment on unit Adequate intake of fluids (2 Liters) during diarrhea episodes Scratch test to assess for allergy on order if penicillin is the only drug of choice Discard after 24 hours if stored at room temperature and 48 hours if refrigerated Teach patient / Family Culture may be taken after completed course of medication To report sore throat, bruising, fever or fatigue To wear or carry emergency ID if allergic to penicillin To notify diarrhea to health care provider

METRONIDAZOLE

Action It has direct-acting amebicide/trichomonacide binds, disrupts DNA structure inhibiting bacterial nucleic acid synthesis.

Uses Intestinal amebiasis, bacterial anaerobic infection, septicemia, endocarditis, bone, joints infections, lower respiratory tract infections.

Side Effects Nausea and vomiting diarrhea, epigastric pain, constipations, pseudomembranous colitis, vaginal dryness, polyuria, neurotoxicity, leukopenia, bone marrow depression, rash.

Nursing Considerations Assess For infection: WBC, wound symptoms , fever, skin or vaginal secretion, start treatment after C&S Allergic reaction: fever, rash, itching, chills; drug should be discontinued if these symptoms occur Neurotoxicity: peripheral neuropathy, seizures, dizziness, incoordination, pruritus, joint pains; drug may be discontinued Perform / Provide Do not refrigerate Administer IV after dilution Evaluate Therapeutic response: decreased symptoms of infection Teach patient / Family



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To complete full course of drug therapy To notify the physician of numbness or tingling of extremities Proper hygiene after bowel movement, hand-hygiene technique To use frequent sips of water or candy for dry mouth To avoid hazardous activities, since dizziness may occur

Midazolam

Action Depresses subcortical levels in CNS; may act on limbic system and reticular formation;

may potentiate -aminobutyric acid (GABA) by binding to specific benzodiazepine receptors.

Uses Preoperative sedation, general anesthesia induction, sedation for diagnostic endoscopic procedures, intubation, anxiety.

Side Effects Retrograde amnesia, confusion, headache, anxiety, insomnia, slurred speech, tremors, weakness, hypotension, blurred vision, nausea, vomiting, apnea, bronchospasm, laryngospasm, respiratory depression.

Nursing Considerations Assess Injection site for redness, pain, swelling Apnea, respiratory depression that may be increased in geriatric patients Perform / Provide Assistance with ambulation until drowsy period relieved Immediate availability of resuscitation equipment, O2 to support airway, do not give by rapid bolus Evaluate Therapeutic response: induction of sedation, general anesthesia Teach patient / Family That amnesia occurs; events may not be remembered

INSULIN

Time Course Agent Onset Peak Duration Indications Rapid acting Lispro (Humalog)

Aspart (Novolog) 10-15 min 5-15 min

I h 40-50 min

2-4 h 2-4 h

Rapid reduction of glucose levels (postprandial hyperglycemia, prevent nocturnal hypoglycemia)

Short acting Regular 0.5 to 1 h 2-3 h 4-6 h 20-30 minutes before a meal

Intermediate acting

NPH 2-4 h 4-12 h 16-20 h Taken after food

Long acting Ultralente 6-8 h 12-16 h 20-30 h Controls fasting glucose levels

Very-long acting Glargine (lanctus) 1 h Continuous 24 h Used as a basal dose

PHARMACODYNAMICS (ACTIONS)

Storage of glucose as glycogen

Increases protein and fat synthesis

Slowing the breakdown of glycogen, protein and fat

Movement of K+ from ECF into cell

Balancing of fluid and electrolyte



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PHARMACOTHERAPEUTICS (INDICATIONS)

Type I DM.

Type II DM. o when other methods of controlling blood glucose level have failed or is contraindicated

(pregnancy or hypersensitivity). o when blood glucose levels are elevated during emotional or physical stress (infection,

trauma, surgery or MI).

Complications of diabetes (Diabetic ketoacidosis (DKA) & Hyperosmolar hyperglycemic nonketotic syndrome (HHNS).

Gestational diabetes when diet regimen fails. ADVERSE EFFECTS

Hypoglycemia (overdose of insulin, missed meal, an unusual physical activity) o Signs and symptoms: fatigue, dizziness, cold sweat, head ace, nervousness, weakness,

mental lapse. o Complications: convulsions and coma if not treated.

Lipodystrophy

Insulin resistance. Nursing Considerations Assess

Fasting blood glucose

Urine ketones during illness, insulin requirements may increase during stress, illness, surgery

For hypoglycemic reaction that can occur during peak time (sweating, weakness, dizziness, chills, confusion, headache, nausea, rapid weak pulse, slurred speech, staggering gait, anxiety, tremors, hunger)

For hyperglycemic: acetone breath, polyuria, fatigue, polydipsia, flushed, dry skin, lethargy Administer

Subcutaneous route: warm to room temperature by rotating in palms to prevent injecting cold insulin. Use only insulin syringes and sites include: abdomen, upper back, thighs, upper arm, buttocks and rotate the sites.

Continuous subcutaneous route (insulin infusion )

IV route Perform / Provide

Store at room temperature for more than 1 month

Keep away from heat and sunlight

Refrigerate all other supply but do not freeze Evaluate

Therapeutic response: decrease in polyuria, polydipsia, polyphagia, clear sensorium, absence of dizziness, stable gait



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Teach Patient/Family

That blurred vision occurs, not to change corrective lens until vision is stabilized 1-2 months

To keep insulin, equipment available at all times, carry a glucagon kit, candy or lump of sugar to treat hypoglycemia

That insulin does not treat diabetes but controls symptoms

To carry emergency ID as diabetic

To recognize hypoglycemia reaction: headache, tremors, fatigue, weakness

To recognize hyperglycemia reaction: frequent urination, thirst, fatigue, hunger.

The dosage, route, mixing instructions, if an diet restrictions, disease process

The symptoms of ketoacidosis: nausea, thirst, polyuria, dry mouth, decreased B.P, dry, flushed skin, acetone breath, drowsiness, Kussmaul respiration.

Plan for diet and exercise

Make sure that the patient can determine glucose levels with blood glucose testing

To avoid OTC products unless directed by prescriber ORAL ANTIDIABETIC DRUGS These drugs are considered after the dietary and exercise regimens have failed to achieve the therapeutic target. PHARMACOTHERAPEUTICS (INDICATIONS)

Biguanides (Metformin) – newly diagnosed type 2 DM.

Sulfonylureas – type 2 DM (when diet and exercise fail).

Sulfonyureas + Insulin – type 2 DM patients who do not respond to drug alone. ADVERSE EFFECTS

Sulfonylureas Biguanides (Metformin)

Stimulate appetite Weight gain Hypoglycemia Skin rashes Bone marrow damage Epigastric fullness Water retention Hyponatremia Photosensitivity

Metallic taste Gastrointestinal disturbances Lactic acidosis

Nursing Considerations Assess

For hypoglycemic reactions (sweating, weakness, dizziness, anxiety, tremors, hunger) and hyperglycemic reactions soon after meals

CBC every 3 months, LFT, AST, LDH, renal studies (BUN, creatinine), glucose during treatment



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For lactic acidosis: malaise, myalgia, abdominal distress, risk increases with age, poor renal function, monitor electrolytes, lactate, pyruvate, blood pH, ketones, and glucose

Administer

PO route: don’t break, crush, or chew the tablet. Give twice daily with meals to decrease GI upset and better absorption

Perform/provide

Store in a tight container in cool environment Evaluate

Therapeutic response: decrease in polyuria, polydipsia, polyphagia, clear sensorium, absence of dizziness, stable gait, blood glucose, A1C at normal level.

Teach Patient / Family

Lactic acidosis symptoms: hyperventilation, fatigue, malaise, chills, myalgia, somnolence

To use regular self-monitoring of blood glucose using blood glucose meter

The symptoms of hypo/hyperglycaemia and what to do about each

That product must be continued on daily basis, explain consequence of discontinuing product abruptly

To avoid OTC medications, alcohol unless approved by prescriber

That diabetes is a lifelong illness, that this product is not a cure, only controls symptoms

To carry emergency ID and glucagon emergency kit for emergencies

To take with first meal of the day

Types of Wound Dressings, Wound Drains and Wound Assessment General Categories of Wound Dressings:

A primary dressing is one that is placed directly on the wound immediate contact surface to perform a function, like interactive dressing, Jelonet, and Nu-Gel.

A secondary dressing is one that is used to hold the primary in place. Ideal Wound Dressing should:

Maintain a moist environment at the wound/dressing interface

Absorb excess exudates without leakage to the surface of the dressing

Provide thermal insulation and mechanical protection

Provide bacterial protection

Allow gaseous and fluid exchange

Absorb wound odors

Be non-adherent to the wound and easily removed without trauma

Be functional: provide some debridement action (remove dead tissue and/or foreign particles)

Be non-toxic, non-allergenic and non-sensitizing (to both patient and medical staff)

Be Sterile

Conform to body surface Types of Wound Dressings:

Occlusive Dressings - Cover topical medications



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e.g., gauze and tape, duderm dressing and opposite dressing

Wet Dressings - for acute, dry, inflammatory lesions e.g., Absolete

Moisture Retentive Dressings Advantage of this over wet dressing is it offers improved fibrinolysis, accelerating epidermal resurfacing, reduced pain, fewer infections, less scar tissue, gentle autolytic debridement and decreased frequency of dressing change e. g. Hydrogels, hydrocolloids, foam dressings, calcium alginates

Hydrogels: Polymers with 90-95 % water content ideal for autolytic debridement of

wounds. They are available as impregnated sheets or gel in a tube. Require secondary dressing. Semitransparent allowing wound inspection without removal of dressing. They are comfortable and soothing for painful wounds. Appropriate for wounds with high serous output. (e.g., IntraSite Gel , Nu-Gel, Vigilon)

Hydrocolloids: Available as sheets and in gels. Good choice for exudative wounds and for acute wounds. Promote debridement and formation of granulation tissue. Can be left in place for 7 days. Non permeable to water vapor and oxygen. (e.g., DuoDERM, Restore, Tegasorb)

Foam Dressings: Consist of micro porous poly urethane with absorptive hydrophilic surface

that covers the wound and a hydrophobic backing to block leakage of exudates. They are non-adherent and require secondary dressing to keep in place. Moisture is absorbed into the foam layer, decreasing maceration of surround tissue. A moisture environment is maintained and removal of the dressing does not damage the wound. Good for exudative wounds.

Calcium Alginates: Derived from seaweed and consist of very absorbent calcium alginate fibers. Haemostatic and bioabsorbable. As the exudates is absorbed the fibers turn into viscous hydrogel. Useful for absorption of heavy to moderate wound exudates in superficial and deep wounds. (e.g., Kaltostat, Sorbsan)

Types of Wound Drains: Drains are tubes that exit the peri-incisional area either into a portable wound suction device or into the dressing. It allows the escape of fluids that could otherwise serve as a culture medium for bacteria. In Portable wound suction, the use of gentle constant suction enhances drainage of these fluids thus removing dead space. Types of wound drains include Penrose, Redivac and Jackson-Pratt drains. Excessive amount of wound drainage should be reported to the surgeon.

A Penrose drain is a surgical device placed in a wound to drain fluid. It consists of a soft rubber tube placed in a wound area, to prevent the buildup of fluid.



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Jackson-Pratt drain, JP drain, or Bulb drain, is a drainage device used to pull excess fluid from the body by constant suction. The device consists of a flexible plastic bulb -- that connects to an internal plastic drainage tube.

Redivac Drain (a close drain) is a fine tube with many holes at the end, which is attached to an evacuated glass bottle providing suction. It is used to drain blood beneath the skin, e.g. after mastectomy or thyroidectomy.

Ongoing Assessment of the Wound:

Inspection of wound edges (for good approximation of wound edges)

Good integrity of sutures or staples

Inspect wound edge for redness, discoloration, warmth, swelling, unusual tenderness or drainage (infection?)

Inspect wound bed for the presence of healthy granulation and epithelialization

Inspect the area around the wound for reaction to a tape or trauma from tight bandages.

Assess for exudates: o Color, Type, and Amount o Odors

Offensive: Necrosis, Anaerobic infection Colonisation, Fungating

Assess for pain

Inspect wound site for infection, ischemia, or compression

Wound Type Wound Description Dressing Type

Clean, medium-to-high exudates (epithelialising)

Paraffin gauze Knitted viscose primary dressing

Clean, dry, low exudates (epithelialising)

Absorbent perforated plastic film-faced dressing Vapour-permeable adhesive film dressing



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Clean, exudating (granulating) Hydrocolloids Foams Alginates

Slough-covered Hydrocolloids Hydrogels

Dry, necrotic Hydrocolloids Hydrogels

Blood Transfusion

What is Blood Transfusion? A blood transfusion is the introduction of whole blood or blood components into the venous circulation. What are the common Blood products for Transfusion?

Product Use

Whole blood Acute hemorrhage, replace blood volume.

Red blood cells Anemia, surgery.

Platelets Platelet deficiency, bleeding disorder

Fresh frozen plasma Provide clotting factors

Albumin and plasma protein Blood volume expander

Clotting factors Clotting factor deficiencies



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What are the indications for blood transfusion?

Bleeding (Internal or external)

Anemia

Not enough blood-making cells (.e.g.: leukemia)

Chemotherapy

Surgery

Radiation What are the Purposes of Blood Transfusion?

To restore blood volume after severe hemorrhage

To restore the capacity of the blood to carry oxygen

To provide plasma factors or platelets to treat bleeding Procedure Assessment:

Clinical signs of reactions

Manifestations of hypervolemia

Any unusual symptoms Planning:

Verify physician order for transfusion

Verify client consent

Assess vital signs

Determine any known allergies

Note specific signs related to client pathology (e.g., note HB level for anemic patient) Equipment:

Unit of blood

Blood administration set

IV Pole

Cannula

Alcohol swab

Tape

Clean gloves Implementation:

Explain the procedure to the client o Purpose o Adverse effects

Obtain the correct blood component o Check the Doctor’s order o Check the requisition form and the blood bag label (patient name, ID number, blood

type [A,B,AB,O and Rh group], and expiration date)

Verify the client’s identity (full name, ID)



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Check with another nurse the patient identity and correct blood

Identify the right patient

Put on gloves

Close all clamps

Prime the tubing with normal saline after filled the chamber

After confirming there is no air bubbles inside the tubing start the blood transfusion

Check the vital signs every 30 minutes throughout the transfusion

Document: vital signs, type of blood, blood unit no, site of the venipuncture, size of the needle, and drip rate

SQUH Routine (Day Care):

After the Doctor’s order o Check the ID o Start the Cannula o Sent the blood for cross matching o Provide the bed o After arrival of blood bag from blood bank, check for right blood and patient. o Start the transfusion and check the vitals every 15 minutes for first one hour and after

that every 30 minutes o Document the details

Points to remember:

Use big gauge cannula (#18 or #19)

Don’t administer blood to a client without an arm band.

Ensure that blood is left at room temperature for no more than 30 minutes before starting the infusion. The reasons are:

o RBC deteriorate and lose their effectiveness o Lysis of RBCs releases potassium into the blood stream cause hyperkalemia o Risk of bacterial growth also increases

Hang the container on the IV pole about 1 meter

First 5-10 minutes: o Run the blood slowly (20 drops /minute) o Note for side effects o Be with the patient

Follow the agency protocol for appropriate disposition of the blood bag What are the complications of blood transfusion?

Reaction Clinical Signs Nursing Interventions

Hemolytic Reaction Chills, fever, headache, backache, dyspnea, cyanosis, chest pain, tachycardia, hypotension

Discontinue the transfusion immediately

Start IV normal saline

Send the remaining sample to lab

Notify the physician

Monitor vital signs

Febrile Reaction Fever, chills, warm, flushed skin,

Discontinue the transfusion immediately

Give antipyretics as ordered



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headache, anxiety, muscle pain



Allergic Reaction-Mild

Flushing, itching, urticaria, bronchial wheezing

Stop or slow the transfusion


Administer antihistamines as ordered

Allergic Reaction-Severe

Dyspnea, chest pain, circulatory collapse, cardiac arrest

Stop the transfusion



Monitor vital signs

CPR if needed

Start O2 as prescribed

Circulatory Overload Cough, dyspnea, crackles (rales), distended neck vein, tachycardia, hypertension

Administer diuretics

Start O2 as prescribed


Stop or slow the infusion

Place the client upright, with feet dependent

Sepsis High fever, chills vomiting, diarrhea, hypotension

Stop the transfusion

Send the remaining blood to Lab


Administer antibiotics

Administer IV normal saline

Blood Transfusion Flow Rates:

Initial Flow Rate Slowly at no more 1 ml/minute to allow for recognition of an acute adverse reaction Proportionately smaller volume for pediatric patients

Standard Flow Rate - Adults If no reaction occurs in the first 15 minutes, the rate may be increased to 4 ml/minute

Standard Flow Rate - Pediatrics 10-20 ml/kg over 30-60 minutes

Usual Infusion time Red Blood Cells: Two hours unless the patient can tolerate only gradual expansion of the intravascular volume Platelets, plasma and cryoprecipitate: 10 ml per minute. The transfusion may be administered as rapidly as the patient can tolerate, usually 30 minutes

Maximum Infusion Time Infusion time should not exceed 4 hours for any component.

If rate slows appreciably Investigate immediately Consider measures that may enhance blood flow:

repositioning the patient's arm,

changing to a larger gauge needle,

changing the filter and tubing,

Elevating the IV pole, if gravity rather than a pump is being used.



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Common Investigations in Clinical Physiology Lab

Investigation 1: Electrocardiography

The ECG is a graphic representation of the electrical currents of the heart.

The ECG is obtained by placing disposable electrodes in standard positions on the skin of the chest wall and extremities.

Recordings of the electrical current flowing between two electrodes is made on graph paper or displayed on a monitor.

Several different recordings can be obtained by using a variety of electrode combinations, called leads.

Simply stated, a lead is a specific view of the electrical activity of heart. The standard ECG is composed of 12 leads or 12 different views, although it is possible to record 15 or 18 leads.

The 12-lead ECG is used to diagnose dysrhythmias, conduction abnormalities, chamber enlargement, and myocardial ischemia, injury, or infarction. It can also suggest cardiac effects of electrolyte disturbances (high or low calcium and potassium levels) and the effects of antiarrhythmic medications.

To enhance interpretation of the ECG, the patient’s age, gender, BP, height, weight, symptoms, and medications (especially digitalis and antiarrhythmic agents) are noted on the ECG requisition.



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ECG electrode placement.

The standard left pre-

cordial leads are V1—fourth

intercostal space, right

sternal border; V2—fourth

intercostal space, left

sternal border; V3—

diagonally between V2and

V4; V4—fifth intercostal

space, left midclavicular

line; V5—same level as V4,

anterior axillary line; V6(not

illustrated)—same level as

V4and V5, midaxillary line.

The right precordial leads,

placed across the right side

of the chest, are the mirror

opposite of the left leads.

RA, right arm; LA, left arm;

RL, right leg; LL, left leg.



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Ambulatory Electrocardiography Ambulatory electrocardiography is a form of continuous ECG monitoring used for diagnostic purposes in the outpatient setting. Electrodes (number varies based on model used) are connected with lead wires to a cable that is inserted into a portable recorder (i.e., Holter monitor) that records the ECG onto a digital memory device. The patient wears the Holter monitor for 24 hours to detect dysrhythmias or myocardial ischemia that may occur during waking hours or sleep. The patient keeps a diary, noting the time of any symptoms or performance of unusual activities. Data from the digital memory device are uploaded into a computer for analysis, and rhythms that need further evaluation by a clinician are identified. Ambulatory electrocardiography is used to identify the etiology of symptoms (e.g., syncope, palpitations) that may be caused by dysrhythmias, to detect episodes of myocardial ischemia, and to evaluate effectiveness of cardiac medications (e.g., antiarrhythmic medications, nitrates) or pacemaker function. Investigation 2: Cardiac Stress Testing Normally, the coronary arteries dilate to four times their usual diameter in response to increased metabolic demands for oxy-gen and nutrients. However, coronary arteries affected by atherosclerosis dilate less, compromising blood flow to the myocardium and causing ischemia. Therefore, abnormalities in cardiovascular function are more likely to be detected during times of increased demand, or “stress.” The cardiac stress test is a non-invasive way to evaluate the response of the cardiovascular system to stress. The stress test helps determine the following :

(1) presence of CAD, (2) cause of chest pain, (3) functional capacity of the heart after an MI or heart surgery, (4) effectiveness of antianginal or antiarrhythmic medications, (5) dysrhythmias that occur during physical exercise, and (6) Specific goals for a physical fitness program.

Contraindications to stress testing include severe aortic stenosis, acute myocarditis or pericarditis, severe hypertension, suspected left main CAD, HF, and unstable angina. Because complications of stress testing can be life-threatening (MI, cardiac arrest, HF, and severe dysrhythmias), testing facilities must have staff and equipment ready to provide treatment, including advanced cardiac life support. Stress testing is often combined with echocardiography or radionuclide imaging. These techniques are performed during the resting state and immediately after stress testing.



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Exercise Stress Testing

A. Procedure

During an exercise stress test, the patient walks on a treadmill (most common), pedals a stationary bicycle, or uses an arm crank. Exercise intensity progresses according to established protocols.

The goal is to increase the heart rate to the “target heart rate,” which is 80% to 90% of the maximum predicted heart rate based on the patient’s age and gender.

During the test, the following are monitored: two or more ECG leads for heart rate, rhythm, and ischemic changes; BP; skin temperature; physical appearance; perceived exertion; and symptoms, including chest pain, dyspnea, dizziness, leg cramping, and fatigue.

The test is terminated when the target heart rate is achieved or when the patient experiences chest pain, extreme fatigue, a decrease in BP or pulse rate, serious dysrhythmias or ST-segment changes on the ECG, or other complications.

When significant ECG abnormalities occur during the stress test (ST-segment depressions or elevations), the test result is reported as positive and further diagnostic testing such as a cardiac catheterization is required.

Ambulatory Electrocardiography Ambulatory electrocardiography is a form of continuous ECG monitoring used for diagnostic purposes in the outpatient setting. Electrodes (number varies based on model used) are connected with lead wires to a cable that is inserted into a portable recorder (i.e., Holter monitor) that records the ECG onto a digital memory device. The patient wears the Holter monitor for 24 hours to detect dysrhythmias or myocardial ischemia that may occur during waking hours or sleep. The patient keeps a diary, noting the time of any symptoms or performance of unusual activities. Data from the digital memory device are uploaded into a computer for analysis, and rhythms that need further evaluation by a clinician are identified. Ambulatory electrocardiography is used to identify the etiology of symptoms (e.g., syncope, palpitations) that may be caused by dysrhythmias, to detect episodes of myocardial ischemia, and to evaluate effectiveness of cardiac medications (e.g., antiarrhythmic medications, nitrates) or pacemaker function.



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Investigation 2: Cardiac Stress Testing Normally, the coronary arteries dilate to four times their usual diameter in response to increased metabolic demands for oxy-gen and nutrients. However, coronary arteries affected by atherosclerosis dilate less, compromising blood flow to the myocardium and causing ischemia. Therefore, abnormalities in cardiovascular function are more likely to be detected during times of increased demand, or “stress.” The cardiac stress test is a non-invasive way to evaluate the response of the cardiovascular system to stress. The stress test helps determine the following :

(7) presence of CAD, (8) cause of chest pain, (9) functional capacity of the heart after an MI or heart surgery, (10) effectiveness of antianginal or antiarrhythmic medications, (11) dysrhythmias that occur during physical exercise, and (12) specific goals for a physical fitness program.

Contraindications to stress testing include severe aortic stenosis, acute myocarditis or pericarditis, severe hypertension, suspected left main CAD, HF, and unstable angina. Because complications of stress testing can be life-threatening (MI, cardiac arrest, HF, and severe dysrhythmias), testing facilities must have staff and equipment ready to provide treatment, including advanced cardiac life support. Stress testing is often combined with echocardiography or radionuclide imaging. These techniques are performed during the resting state and immediately after stress testing. Exercise Stress Testing

B. Procedure

During an exercise stress test, the patient walks on a treadmill (most common), pedals a stationary bicycle, or uses an arm crank. Exercise intensity progresses according to established protocols.

The goal is to increase the heart rate to the “target heart rate,” which is 80% to 90% of the maximum predicted heart rate based on the patient’s age and gender.

During the test, the following are monitored: two or more ECG leads for heart rate, rhythm, and ischemic changes; BP; skin temperature; physical appearance; perceived exertion; and symptoms, including chest pain, dyspnea, dizziness, leg cramping, and fatigue.

The test is terminated when the target heart rate is achieved or when the patient experiences chest pain, extreme fatigue, a decrease in BP or pulse rate, serious dysrhythmias or ST-segment changes on the ECG, or other complications.

When significant ECG abnormalities occur during the stress test (ST-segment depressions or elevations), the test result is reported as positive and further diagnostic testing such as a cardiac catheterization is required.



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A. Nursing Interventions

In preparation for the exercise stress test, the patient is instructed to fast for 4 hours before the test and to avoid stimulants such as tobacco and caffeine.

Medications may be taken with sips of water.

The physician may instruct the patient not to take certain cardiac medications, such as beta-adrenergic blocking agents, before the test.

Clothes and sneakers or rubber-soled shoes suitable for exercising are to be worn.

The nurse prepares the patient for the stress test by describing how the stress test is performed, the type of monitoring equipment used, the rationale for having an IV catheter inserted, and what symptoms to report.

The exercise method is reviewed and patients are asked to put forth their best exercise effort. If the test is to be performed with echocardiography or radionuclide imaging, this information is reviewed as well.

After the test, the patient is monitored for 10 to 15 minutes. Once stable, patients may resume their usual activities.

Investigation 3: Echocardiography Traditional Echocardiography Echocardiography is a noninvasive ultrasound test that is used to measure the ejection fraction and examine the size, shape, and motion of cardiac structures. It is particularly useful for diagnosing pericardial effusions; determining chamber size and the etiology of heart murmurs; evaluating the function of heart valves, including prosthetic heart valves; and evaluating ventricular wall motion.

A. Procedure

Echocardiography involves transmission of high-frequency sound waves into the heart through the chest wall and recording of the return signals.

The ultrasound is generated by a handheld transducer applied to the front of the chest.

The transducer picks up the echoes, converts them to electrical impulses, and transmits them for display on an oscilloscope and recording on a videotape. An ECG is recorded simultaneously to assist with interpreting the echocardiogram.

Two-dimensional or cross-sectional echocardiography creates a sophisticated, spatially correct image of the heart. Other techniques, such as Doppler and color flow imaging echocardiography, show the direction and velocity of the blood flow through the heart.

Echocardiography may be performed with an exercise or pharmacologic stress test. Images are obtained at rest and then immediately after the target heart rate is reached. Myocardial ischemia from decreased perfusion during stress causes abnormalities in ventricular wall motion and is easily detected by echocardiography.



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A stress test using echocardiography is considered positive if abnormalities in ventricular wall motion are detected during stress but not during rest. These findings are highly suggestive of CAD and require further evaluation, such as a cardiac catheterization.

B. Nursing Interventions

Before echocardiography, the nurse informs the patient about the test, explaining that it is painless.

Echo cardiographic monitoring is performed while a transducer that emits sound waves is moved over the surface of the chest wall.

Gel applied to the skin helps transmit the sound waves.

Periodically, the patient is asked to turn onto the left side or hold a breath.

The test takes about 30 to 45 minutes.

If the patient is to undergo an exercise or pharmacologic stress test with echocardiography, information on stress testing is also reviewed with the patient.

Transesophageal Echocardiography

A. Procedure

A significant limitation of traditional echocardiography is the poor quality of the images produced. Ultrasound loses its clarity as it passes through tissue, lung, and bone. An alternate technique involves threading a small transducer through the mouth and into the esophagus. This technique, called transesophageal echocardiography (TEE), provides clearer images because ultrasound waves pass through less tissue.

A topical anesthetic agent and moderate sedation are used during a TEE because of the discomfort associated with the positioning of the transducer in the esophagus.

Once the patient is comfortable, the transducer is inserted into the mouth and the patient is asked to swallow several times until it is positioned in the esophagus.

The high-quality imaging obtained during TEE makes this technique an important first-line diagnostic tool for evaluating patients with many types of CVD, including HF, valvular heart disease, dysrhythmias, and many other conditions that place the patient at risk for atrial or ventricular thrombi.

Pharmacologic stress testing using dobutamine and TEE can also be performed.

It is frequently used during cardiac surgery to continuously monitor the response of the heart to the surgical procedure (eg, valve replacement or coronary artery bypass).

Complications are uncommon during TEE, but if they do occur, they are serious. These complications are caused by sedation and impaired swallowing resulting from the topical anesthesia (respiratory depression and aspiration) and by insertion and manipulation of the transducer into the esophagus and stomach (vasovagal response or esophageal perforation). The patient must be assessed before TEE for a history of dysphagia or radiation therapy to the chest, which increases the likelihood of complications.



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B. Nursing Interventions

Prior to the test the nurse provides pre-procedure education and ensures that the patient has a clear understanding of what the test entails and why it is being performed, instructs the patient not to eat or drink anything for 6 hours prior to the study, and checks to make sure that informed consent has been obtained.

The nurse also inserts an IV line or assesses an existing IV for patency and asks the patient to remove full or partial dentures.

During the test, the nurse pro-vides emotional support and monitors level of consciousness, BP, ECG, respiration, and oxygen saturation (SpO2).

During the recovery period, the patient must maintain bed rest with the head of the bed elevated to 45 degrees.

Following the moderate sedation policy of the agency, the nurse monitors the patient for dyspnea and assesses vital signs, SpO2, level of consciousness, and gag reflex as recommended.

Food and oral fluids are withheld until the patient is fully alert and the effects of the topical anesthetic agent are reversed, usually 2 hours after the procedure; if gag reflex is intact, the nurse begins feeding with sips of water, and then advances to pre-procedure diet.

The patient is informed that a sore throat may be present for the next 24 hours; he or she is instructed to report the presence of a persistent sore throat, shortness of breath, or difficulty swallowing.

If the procedure is performed in an outpatient setting, a family member or friend must be available to transport the patient home

Investigation 5: Pulmonary Function Tests Pulmonary function tests (PFTs) are routinely used in patients with chronic respiratory disorders. They are performed to assess respiratory function and to determine the extent of dysfunction. Such tests include measurements of lung volumes, ventilatory function, and the mechanics of breathing, diffusion, and gas exchange. PFTs are useful in monitoring the course of a patient with an established respiratory disease and assessing the response to therapy. They are useful as screening tests in potentially hazardous industries, such as coal mining and those that involve exposure to asbestos and other noxious fumes, dusts, or gases. Prior to surgery, they are used to screen patients who are scheduled for thoracic and upper abdominal surgical procedures, patients who are obese, and symptomatic patients with a history suggesting high risk. PFTs generally are performed by a technician using a spirometer that has a volume-collecting device attached to a recorder that demonstrates volume and time simultaneously. A number of tests are carried out because no single measurement provides a complete picture of pulmonary function.



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The most frequently used PFTs are described in the Table below.

PFT results are interpreted on the basis of the degree of deviation from normal, taking into consideration the patient’s height, weight, age, and gender. Because there is a wide range of normal values, PFTs may not detect early localized changes. The patient with respiratory symptoms (dyspnea, wheezing, cough, sputum production) usually undergoes a complete diagnostic evaluation, even if the results of PFTs are “normal.” Trends of results provide information about disease progression as well as the patient’s response to therapy. Patients with respiratory disorders may be taught how to measure their peak flow rate (which reflects maximal expiratory flow) at home using a spirometer. This allows them to monitor the progress of therapy, to alter medications and other interventions as needed based on caregiver guidelines, and to notify the health care provider if there is in adequate response to their own interventions.



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Investigation 6: Computed Tomography Scanning

Computed tomography (CT) scanning uses a narrow x-ray beam to scan body parts in successive layers. The images provide cross-sectional views of the brain, distinguishing differences in tissue densities of the skull, cortex, subcortical structures, and ventricles. An intravenous (IV) contrast agent may be used to highlight differences further.

The image is displayed on an oscilloscope or TV monitor and is photographed and stored digitally.

CT scanning is usually performed first without contrast material and then with IV contrast, if needed. The patient lies on an adjustable table with the head in a head rest while the scanning system rotates around the body part and produces cross-sectional images.

CT scanning is quick and painless and uses a small amount of radiation to produce images; it has a high degree of sensitivity for detecting lesions.

Nursing Interventions

Essential nursing interventions include preparation for the procedure and patient monitoring. Preparation includes teaching the patient about the need to lie quietly through-out the procedure.

A review of relaxation techniques maybe helpful for patients with claustrophobia.

Sedation can be used if agitation, restlessness, or confusion interferes with a successful study.

Ongoing patient monitoring during sedation is necessary.

If a contrast agent is used, the patient must be assessed before the CT scan for an iodine/shellfish allergy, because the contrast agent used may be iodine based. Renal function must also be evaluated, as the contrast material is cleared through the kidneys.

A suitable IV line for contrast injection and a period of fasting (usually 4 hours) are required prior to the study.

Patients who receive an IV contrast agent are monitored during and after the procedure for allergic reactions and changes in kidney function.

Investigation 7: Magnetic Resonance Imaging

MRI uses a powerful magnetic field to obtain images of different areas of the body.

The magnetic field causes the hydrogen nuclei (protons) within the body to align like small magnets in a magnetic field.

In combination with radiofrequency pulses, the protons emit signals, which are converted to images.

An MRI scan can be performed with or without a contrast agent and can identify abnormalities earlier and more clearly than several other diagnostic tests.

It can provide information about the chemical changes within cells, allowing the clinician to monitor a tumor’s response to treatment.

It is particularly useful in the diagnosis of brain tumor, stroke, and multiple sclerosis, and does not involve ionizing radiation.

A complete MRI scan may take an hour or longer to complete.



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Nursing Interventions

Patient preparation includes teaching and obtaining an adequate history. Ferromagnetic substances in the body may become dislodged by the magnet, so history of working with metal fragments must be reviewed. The patient is questioned about any implants of any metal objects (e.g., aneurysm clips, orthopedic hardware, pacemakers, artificial heart valves). These objects could malfunction, be dislodged, or heat up as they absorb energy. Cochlear implants will be inactivated by MRI; therefore, other imaging procedures are considered.

Before the patient enters the room where the MRI is to be performed, all metal objects and credit cards (the magnetic field can erase them) must be removed. This includes medication patches that have a metal backing and metallic lead wires; these can cause burns if not removed. No metal objects may be brought into the room where the MRI is located; this includes oxygen tanks, IV poles, ventilators, or even stethoscopes.

The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and literally can be pulled away with such force that they fly like projectiles toward the magnet. There is a risk of severe injury and death. Further, damage to expensive equipment may occur.

Investigation 8: Electroencephalography

An electroencephalogram (EEG) represents a record of the electrical activity generated in the brain. It is obtained through electrodes applied on the scalp or through microelectrodes placed within the brain tissue. It provides an assessment of cerebral electrical activity. It is useful for diagnosing and evaluating seizure disorders, coma, or organic brain syndrome.

Tumors, brain abscesses, blood clots, and infection may cause abnormal patterns in electrical activity. The EEG is also used in making a determination of brain death. Electrodes are applied to the scalp to record the electrical activity in various regions of the brain. The amplified activity of the neurons between any two of these electrodes is recorded on continuously moving paper; this record is called the encephalogram.

For a baseline recording, the patient lies quietly with both eyes closed. The patient may be asked to hyperventilate for 3 to 4 minutes or to look at a bright, flashing light for photic stimulation. These activation procedures are per-formed to evoke abnormal electrical discharges, such as seizure potentials. A sleep EEG may be recorded after sedation because some abnormal brain waves are seen only when the patient is asleep.

Anti-seizure agents, tranquilizers, stimulants, and depressants should be withheld 24 to 48 hours before an EEG because these medications can alter the EEG wave patterns or mask the abnormal wave patterns of seizure disorders.

Coffee, tea, chocolate, and cola drinks are omitted in the meal before the test because of their stimulating effect. However, the meal is not omitted, because an altered blood glucose level can cause changes in brain wave patterns.

The patient is informed that the standard EEG takes 45 to 60 minutes; a sleep EEG requires 12 hours. The patient is assured that the procedure does not cause an electric shock and that the EEG is a diagnostic test, not a form of treatment.

An EEG requires the patient to lie quietly during the test. Sedation is not advisable, because it may lower the seizure threshold in patients with a seizure disorder and it alters brain wave activity in all



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patients. The nurse needs to check the physician’s prescription regarding the administration of anti-seizure medication prior to testing. Routine EEGs use a water-soluble lubricant for electrode contact, which can be wiped off and removed by shampooing later.

Investigation 9: Electromyography

An electromyogram (EMG) is obtained by inserting needle electrodes into the skeletal muscles to measure changes in the electrical potential of the muscles. The electrical potentials are shown on an oscilloscope and amplified so that both the sound and appearance of the waves can be analyzed and compared simultaneously. An EMG is useful in determining the presence of neuromuscular disorders and myopathies. It helps distinguish weakness due to neuropathy (functional or pathologic changes in the peripheral nervous system) from weakness resulting from other causes. Nursing Interventions

The procedure is explained, and the patient is warned to expect a sensation similar to that of an intramuscular injection as the needle is inserted into the muscle.

The muscles examined may ache for a short time after the procedure. Investigation 10: Nerve Conduction Studies Nerve conduction studies are performed by stimulating a peripheral nerve at several points along its course and recording the muscle action potential or the sensory action potential that results. Surface or needle electrodes are placed on the skin over the nerve to stimulate the nerve fibers. This test is useful in the study of peripheral neuropathies and is often included as part of the EMG.



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Preoperative Care

Preoperative phase starts when a decision to have surgery is made and ends when the patient is transferred to the operating table. Nursing activities includes:

Assessing the patient

Identifying actual or potential health problems

Planning specific care based on individual’s needs

Providing preoperative teaching for patient, family and significant others Important Activities of the Preoperative Phase

1. Preoperative Consent: usually obtained by the surgeon, informed consent implies that the patient has been informed and involved in decisions affecting his or her health. This is done before any surgical procedure.

2. Assessment: involves the history, physical, psychological and social assessment data that is

collected to determine the patient’s needs throughout the perioperative phase.

Preoperative Assessment Data

Current health status(general health status and presence of any chronic disease)

Allergies

Medications

Previous surgeries

Mental status

Understanding of the surgical procedure and anesthesia

Smoking-have difficulty clearing lungs secretions after surgery, have increased risk of developing pneumonia and atelectasis

Alcohol and other mind-altering substances

Coping-surgery can be stressful.

Social resources

Cultural and spiritual considerations 3. Screening Tests: ordered by the surgeon or anesthesiologist. The nurse checks the orders

carefully, carries them out, gets the results and reports abnormal findings. Sometimes patient needs treatment prior to the surgery. Routine Preoperative Screening Tests

Complete blood count (CBC): RBC, Hb and Hct are important to the oxygen carrying capacity of the blood. WBCs are indicators of immune function

Blood grouping and cross-matching: in case blood transfusion is required

Serum electrolytes (Na+, K+, Mg2+, Cl-, HCO3-):evaluate fluid and electrolyte status

Fasting blood glucose: high level can indicate undiagnosed DM



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Blood Urea Nitrogen (BUN) and creatinine: evaluate renal function

ALT,AST, LDH and bilirubin: evaluate liver function

Serum albumin and total protein: evaluate nutritional status

Urinalysis: determine urine composition and possible abnormal components (protein or glucose) or infection

Chest X-ray: evaluate respiratory status and heart size

ECG (all patients over 40 years and those with cardiac conditions): identify pre-existing cardiac problems or disease

HCG (pregnancy test for all female patients of childbearing age): identify if patient is pregnant.

4. Preoperative Teaching: is a vital part of nursing care that reduces patient’s anxiety and

postoperative complications thus increasing patient’s satisfaction with the surgical experience. Good preoperative teaching also facilitates the patient’s successful and early return to work and other ADL. Its provided a day before the surgery Dimensions of Preoperative Teaching

Information including what will happen to the patient, when, and what the patient will experience such as expected sensation and discomfort

Psychosocial support to reduce anxiety whereby the nurse provides support by actively listening and providing accurate information.

The roles of the patient and family/support people in the preoperative preparation, the surgical procedure, and during the postoperative phase. Includes desired behavior of the patient, self-care activities, and what patient has to do to facilitate recovery.

Skills training that include moving/mobilizing the patient, leg exercise, deep breathing, coughing, splinting incision with hands or a pillow, and using an incentive spirometer.

5. Physical Preparation: the nurse completes the agency’s preoperative checklist following

appropriate documenting procedures (SQUH-EPR).

a. Nutrition and fluids:

o Adequate hydration and nutrition promote healing.

o NPO after midnight

o Maintain I&O chart if patient on IV fluids

b. Elimination:

o Bowel preparation (enema) for bowel surgery to prevent postoperative

constipation and contamination.

o Patient is instructed to void before going to OT or a catheter may be inserted

prior to surgery to ensure bladder remains empty

c. Hygiene:

o Bath or shower evening or morning before surgery to reduce risk of wound

infection.



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o Trim nails and remove polish, remove cosmetics from nails, skin and lips so that

they are visible when assessing circulation during perioperative phases

o Wear surgical cap to cover hair and scalp, and surgical gown during

intraoperative phase

d. Medication: anesthetist may order some medications to be stopped and other given

prior to surgery

o Anticoagulants, tranquilizers, corticosteroids and diuretics may increase surgical

risk and maybe stopped

o At SQUH, Midazolam is given once patient is called to OT to calm down the

patient and antibiotics are given 1 hour before surgery

e. Rest and sleep: patient should rest and sleep the night before surgery to reduce stress

f. Valuables:

o Jewellery and money should be sent home with the family or labeled and placed

in a locked storage area as per the agency’s policy.

o Remove body-piercing jewellery to avoid risk of burn injury if an electrosurgical

unit is used.

g. Prostheses:

o all artificial body parts such as partial or complete dentures, contact lenses,

artificial eyes, and artificial limbs should be removed

o eye glasses, wigs, false eyelashes must be removed

o hearing aids are often left and OR personnel informed

o Check for chewing gum and loose teeth among children of 6-7years old because

they can dislodge or be aspirated during anesthesia.

h. Special orders : the nurse has to check the surgeon’s order for special requirement e.g.

insertion of an NGT, or administration of medication prior to surgery

i. Skin preparation: this can include shaving a particular site or surgical marking, the

surgical site is also cleansed with an antimicrobial during the intraoperative phase to

reduce microbial count.

j. Safety protocols: Follows the universal protocol for preventing wrong site, wrong

procedure, wrong person surgery

o Patient verification

o Marking of operative site according to agency policy (SQUH-arrow at side of

body pointing to the site of surgery)

o “Time-out”: before surgery begins, the nurse, surgeon and anesthetist take a

time-out to conduct a final verification of correct patient, procedure and site.

(See the Safe Surgery Checklist at SQUH-OT)

k. Vital signs: assess and document vital signs for baseline data and report any abnormal

findings.



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l. Anti-embolic stockings: antiembolic (elastic) stockings are used to compress veins of the

legs and thus facilitate venous return, improve arterial circulation and prevent edema of

the legs.

Examples of nursing diagnoses: deficient knowledge; anxiety; disturbed sleep pattern; anticipatory grieving; ineffective coping.

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