Recovery Room Equipment

• heart monitoring
• suction equipment measure output (Yankeur suction for nose & mouth, has larger bore catheter (wider & shorter)
• Oxygen nasal canula, ventilator, try to wean off O2 if healthy & before they leave recovery, note O2 sat
• pulse oximeter
• V/S equipment: dynamap checks BP, pt can have it check every minute, print out recording
• SCD (hose that intermittently decompress & compress) & TED hose put on pre-op to ↑circulation to legs to prevent DVT, and ↑return to heart from legs
• PCA pump (initiated by anesthesiologist), monitored by nurse

Complications Cardiovascular Complications

• Hemorrhage
• Shock
• Thrombophlebitis
• Deep vein thrombosis
• Pulmonary embolus
• Leg Exercises to Increase Venous Return nurse should teach pre-op (↑venous return, ↓DVT. use of SCD & TED hose also
• Respiratory Complications pg. 83 LeMone
• Pneumonia
• Atelectasis collapse of alveoli, collapse or incomplete expansion of lung tissue due to inadequate lung ventilation
• Interventions to Prevent (pg 72 L)

Respiratory Complications (atelectasis & pneumonia)

• Monitoring vital signs
• Implementing deep breathing*
• Coughing* (cough every 1-2 hrs = deep cough x4)
• Incentive spirometry* 1-2 hrs
• Turning in bed
• Ambulating
• Maintaining hydration
• Avoiding positioning that decreases ventilation
• Monitoring responses to narcotic analgesics

Urinary Complications (causes: Foleys & anesthesia)

• Urinary retention note output in recovery room chart
• Urinary tract infection

Gastrointestinal Complications

• (avoid gas foods)
• Nausea and vomiting
• Postoperative ileus assess bowel sounds (gut goes to sleep with anesthesia, no solid food until bowel sounds heard. listen for 5 minutes if not heard), Ask pt about flatulence (normal to have some)

Wound Complications

• Infection (S & Sx: swelling, redness, warmth, & drainage) teach pt and family
• Dehiscence separation of suture line
• partial surgeon may leave or may decide to resuture
• complete back to surgery
• concern for morbidly obese needs to be packed*
• Evisceration extrusion of body organs out of wound

Managing pain

• Prior to transfer from recovery room the client's pain should be stabilized
• It is not expected the client be pain free.
• Pain control regimen initiated
• Document level prior to transfer
• Assess for nonverbal pain cues: restlessness, in vitals, ↑heart rate, BP, & respirations

Other expectations prior to transfer

• Stable vital signs & gag reflex present
• Alert and awake easily aroused, understands instructions
• Communicating
• Adequate output
• Toleration of some clear liquids/decrease in N&V
• Stable CV and respiratory system
• Postoperative orders obtained and on chart give report at transfer
• can have orthostatic hypotension when stand up, have pt dangle legs a few mins.
• * don't use nurse's name in chart

Outcomes for the Surgical Patient

• Be free from injury and adverse effects
• Be free from infection
• Maintain fluid and electrolyte balance; skin integrity
• Demonstrate understanding of physiologic and psychological responses to surgery
• Participate in rehabilitation process: can be simple, ie. coughing

Common nursing diagnoses see T. 913, 30-1 skill related to hazards of immobility

• Acute pain risk for falls
• Risk for infection risk for constipation
• Risk for altered skin integrity ineffective coping
• Disturbed body image knowledge deficit
• Risk for urinary retention
• Risk for constipation
• Risk for injury

Developmental / Cultural Considerations Children

• use short simple explanations
• give mini tour of facility, explain what to expect.
• Pay careful attention to parents of infants & children, include them in education, plan of care & procedure as much as possible

Adolescents

• protect privacy
• remember actual age & developmental level of all clients
• be culturally competent
• keep family members informed to ↓anxiety & feeling of being left out, answer family & client questions
• Evaluate teaching & learning during recovery / postop phase.
• ie. coughing & deep breathing, use of ICS, diet, etc. taught before surgery

Postoperative Nursing Care

Stefanie Wortham RNC, MSN Postoperative period

• From the surgical suite to the PACU
• PACU is recovery room
• 1:1 nurse/client ratio until recovery complete
• Last 1-2 hours depending on complications with client
• Transferred to floor following recovery

Recovery Room

• Assessments made every 10-15 minutes
• PCA pump is started and/or orders for pain medication obtained write on flow sheet every 5 minutes (after starts) for first 15 minutes, less frequent over time.
• Anesthesiologist is readily available for any problems related to anesthesia and pain
• Surgeon readily available for any postoperative complications
• Pt needs to be stabilized, awake, & alert before transferring

Assessments Include:

• Respiratory movement of chest - check for symmetry of expansion, equality auscultate, do continuous O2 sat, check ABC
• Cardiovascular 3 lead EKG
• Pain/Comfort pt may be cold, cover with blanket
• Level of Consciousness
• Fluid intake/Intravenous fluids
• Wound/Dressing
• Movement/Sensation
• Anesthesia
• Nausea and vomiting
• Vital signs compare to baseline data
• Color and temperature of skin
• Other tubes check tube patency (chest tubes, endotrach. tube, Foley, NG, JP drain etc)
• Position and safety initially side lying to prevent aspiration, face slightly down.
• Blood sugar if diabetic
• Return of Consciousness never leave unattended
• Unconscious assess LOC & document on flow sheet
• Response to touch and sounds orient to room, reassure
• Drowsiness
• Awake but not oriented
• Awake and oriented

Shock

Postoperative complications

Cardiovascular complications

1. systemic imbalances

2. cellular dysfunction

3. tissue perfusion inadequate

Shock

1. inadequate cellular metabolism & inadequate perfusion & oxygenation (can lead to death)

2. inadequate blood flow & inadequate oxygen results in inadequate oxygen & nutrients to cells,

cellular starvation, cell death, and eventually death

3. blood flow depends on pressure changes – greater to lesser pressure

4. mean pressure is highest in the aorta & lowest in the right atrium (to keep blood circulating)

Shock Results from three aspects of circulation

1. heart pump

2. peripheral resistance; resistance to passage of blood through small vessels (capillaries),

effective vascular & circulatory system with good tone (for vasoconstriction & dilation)

will constrict to ↑BP and dilate to ↓BP. With shock the sympathetic NS will constrict blood

3. blood volume: if pt hemorrhages, have↑risk for shock. The tissues are unable to extract &

use O₂ delivered. Body responds by sympathetic NS activation to constrict blood vessels.

Stroke volume = blood pumped out of aorta 60 ml is normal

Cardiac output = Stroke volume x heart rate (CO= SV x HR)

Mean arterial pressure (MAP) = CO x SVR. *you can use BP to figure out MAP which measures systemic vascular resistance

formula is: (Systolic + 2(Diastolic)) / 3 = MAP

example: for BP of 125/70 formula is (125 + 2(70)) / 3 = 88.33

Three Major types of shock

1. hypovolumic: ↓volume ( ↓intravascular volume)

2. cardiogenic: problem with heart's pumping ability

3. distributive: circulatory or vasoactive shock – alterations in vascular smooth muscle tone (problems

with peripheral resistance)

a. neurogenic: NS injury or reaction to drug (epidural) anesthetic

b. septic: infection

c. anaphylactic: hypersensitivity to drug

Shock involves:

1. hypoperfusion of tissues

2. hypermetabolism by cell

3. activation of inflammatory response to try to get back to homeostasis

Cellular Response – active transport, muscle contraction, & conduction of impulses makes cell more permeable

1. 1. ↓O₂ causes ↓ATP and ↑acid production

2. ↓ATP causes malfunction of Na⁺ and K⁺ pump (Na enters cell and K leaves)

3. ↑Na & water in cell causes cellular edema & further interferes with cell function

4. ↑cellular hypoxia causes ↑release of acid end product causes intracellular acidosis which causes lysosomal membranes to rupture and lytic enzymes to be released

5. lytic enzymes degrade protein, CHO, and fat; and cause death of cell

6. cellular death causes multiple substances to be released in blood stream

cellular response – con't (glucose primary substance used by ATP. glycogen stores depleted)

1. causes hyperglycemia an insulin resistance to mobilize for cellular metabolism

2. activates glycogenesis

3. glycogen stored in liver is converted to glucose through glycogenesis

4. increases the amount of glucose in the bloodstream

5. hyperglycemia

6. continued stress causes depletion of glycogen stores

7. resulting in increased proteolyis & cell death & organ failure

Stages of shock

Early – compensatory

1. stim. sympathetic NS (epinephrine & norepinephrine released to ↑cardiac output send ↑blood

to tissues

2. ↑glucocorticoids & mineralcorticoids cause Na & fluid retention to ↑intravascular volume

3. hypoxemia causes hyperventilation (early respiratory alkalosis)

4. decreased capillary fluid pressure causes fluid shift from interstitial space to intravascular

5. body shunts blood from the skin, kidney, & GI to brain & lungs

Signs & symptoms (early)– classic : decreased BP

1. restlessness, apprehension, feeling of fright

2. bowel sounds hypoactive

3. increased thready weak pulse >100

4. decreased UO (20-30 ml /hr.); decreased urinary Na (because Na retained to↑volume)

5. increased urinary osmolarity [urine concentration]

6. skin – cool & clammy

7. temp. = normal

Medical Management

Identify cause & try to correct

1. Are they losing blood?

2. Do they need meds?

3. Fluid replacement?

Nursing Care

Assess, monitor, evaluate

1. LOC

2. V/S.

3. 40 mmpulse pressure (systolic – diastolic) correlates with stroke volume. normal is 30-40 mm Hg. narrowing of pulse pressure is indicator of shock. report systolic 90

4. UO: 30 ml/hr (best indicator of hypoperfusion) If↓or absent, shock progressed, maintain UO

5. skin

6. with elderly check for hypertension, infections, & decreased organ perfusion. Is it a rxn to drugs?

7. lab

a. blood gases

b. ↑Na and glucose, aldosterone & catecholamines

c. capnography: CO₂ measure

d. gastric tonometry – balloon to measure CO₂ & pH of intestinal mucosa

e. central venous or mixed venous O₂ sat

Administer IV medications

promote pt safety & decrease anxiety

confusion of the 1^st things you see

explain, provide support, speak calmly, use touch, provide safety

Progressive Shock

Progressive

1. mechanisms that regulate BP no longer compensate. 90 40 mm Hg

2. myocardial depression - heart becomes dysfunctional

3.body's inability to meet O₂ requirements produces ischemia

4. autoregulatory function of microcirculation fails – results in ↑capillary permeability, so fluid

leaks from capillaries which causes interstitial edema, less fluid return to heart

5. arteriole & venous constriction further compromise cellular perfusion

6. relaxation of capillary spincters

7. inflammatory response is activated, coagulation response is activated

8. body mobilizes energy stores & increases O₂ consumption to help meet metabolic needs – need

to treat symptoms of shock. Surviving shock depends on health of individual prior to shock.

Signs & Symptoms

1. rapid, shallow respirations with crackles O₂ ↓ CO₂ ↑ due to pulmonary edema (pt can get MI, cardiac enzymes released) BNP (B-type naturetic P) lose consciousness

2. BP 80-90 mm Hg

3. HR 150

4. skin mottled, petechiae

5. UO 5-15 mL / hr (oliguria)

6. lethargy – confused due to hypoxia

7. metabolic acidosis

8. get adult respiratory edema "ARDS" or adult respiratory distress syndrome or "shock lung"

9. check cardiac enzymes: CPK, MB, tryponin I, LDH. these increase when ventricles distended

10. MAP can affect GFR, then BUN & creatinine will be high

GI

1. stress ulcers – can get necrotic / gangrene

2. bloody diarrhea

Hematologic –

1. toxins can pass into bloodstream due to ↑permeability

2. disseminated intravascular coagulation "DIC" from clotting

Nursing care

1. assess for subtle changes

   a. ABG

b. electrolytes

c. mental LOC

d. is pt on dialysis or ventilator?

*balloon in heart can increase cardiac effectiveness "balloon pump"

2. coordinate everything

3. prevent infection

4. promote rest & comfort (get pt warm, but not too warm) – BP will ↓

5. provide support to family

Irreversible – later: not survive

noncompensatory – organ damage severe, continue to treat, but start to make end of life decision

1. decreased blood flow to heart

2. anaerobic metabolism (acidosis)

3. arteriolar dilation

4. decreased blood flow to kidney – aneuric (retention) failure of N-K pump, Na enters cell, shifts to hypovolemia from intravascular to interstitial

5. multiple organ failure

Progresses

1.BP decreases

2.Urinary volume decreases

3.metabolic acidosis

4.signs & symptoms of failure of most organs

Signs & Symptoms

1. BP requires mechanical or pharmacologic support

2. HR erratic or asystole

3. respiratory requires intubation

4. jaundice – liver failure

5. aneuric – requires dialysis

6. unconscious

7. profound acidosis

Stages of general anesthesia

Stages of general anesthesia

A. Stage I (induction) begins with the administration of intravenous agents or with inhalation of a

combination of anesthetic gases and oxygen

Endotracheal intubation is performed or newer devices are used ie. laryngeal mask airway,

esophageal tracheal combitube, or lighted stylet or wand to see vocal cords

B. Stage 2 (maintenance) during this phase the client is positioned, skin prepped, surgery performed

1. once it is safe for any of these activities to begin, then maintenance phase is begun

2. during this phase the appropriate levels of anesthesia are maintained. The depth of anesthesia

can be increased as needed

C. Stage III (emergence phase) this period begins when the anesthesiologist dereases the anesthetic

agents & pt begins to awaken

1. extubation usually occurs during this period

2. complications can occur such as laryngospasm, vomiting, slow spontaneous respirations, &

uncontrolled reflex movement

IV. Factors which place the intraoperative pt at risk;

A. advanced age can decrease tolerance of general anesthesia, physiologic changes in aging can

affect blood, fluid loss & replacement, hypothermia, pain, tolerance of surgical

procedure / position

B. respiratory disorders: respiration depression from general anesthesia & acid / base imbalances

can occur

C. renal & liver dysfunction: may poorly tolerate general anesthesia & can have fluid / electrolye

& acid / base imbalances, decreased metabolism & excretion of drugs

D. alcoholism can increase the amount of anesthesia required

E. medications: anticoagulants (including aspirin) can cause intraoperative hemorrhage

1. diuretics – esp. thiazides can cause fluid & electrolyte imbalances. some are K⁺ sparing,

some are not. can produce altered cardio / vasc response & respiratory depression

2. antihypertensives (esp. phenothiazines) can increase hypotensive affects of anesthesia

3. antidepressants (esp. monoamine oxidase inhibitors) can increase hypotensive affects

4. antibiotics (esp. "mycin") may cause apnea and resp. paralysis

5. herbal supplements – can prolong anesthesia affects. esp. ones with sedative affects,

ie. St. John's wort (can increase bleeding risk, increase BP)

V. Potential Intraoperative Complications

A. Nausea & vomiting: if gagging occurs, turn pt to side & head of bed lowered to prevent aspiration

anesthesiologist can give antiemetics

B. hypoxia & respiratory complications: inadequate ventilation, occlusion of airway, inadvertently

put in esophagus instead of trachea

peripheral perfusion is checked frequently and oxygen sat monitored

C. Hypothermia: body temp below normal 98.0

1. glucose if metabolism is reduced. as a result can have metabolic acidosis?

2. warm solutions can be given, blankets, change any wet gowns, remove wet drapes

read pg 63 about malignant hypertension box 4-1

Types of agents used for general anesthesia

Types of agents used for general anesthesia

A. IV induction agents or total intravenous anesthesia "TIVA" has rapid onset & last only few mins.

This allows time for endo-tracheal tube to be inserted & inhalation agent to be started

1. Clients with a history of malignant hyperthermia should avoid inhalation agents because

they trigger MH (malignant hyperthermia)

2. Examples of IV agents:

Barbituates: pentothal & brevital

Non-barbituates: amidate & diprivan

B. Inhalation agents – may be volatile liquids – room temp = gas

1. Volatile liquids are administered through a specially designed vaporizer after being mixed

with O₂ as a carrier gas

2. enters body through alveoli

3. administered through a mask, endotracheal tube, laryngeal mask airway or tracheostomy

4. Ease of administration & rapid excretion by ventilation make them desirable agenst

5. Non-desirable effect is the irritating effect on respiratory tract

6. Complications that can arise are coughing, laryngospasm, bronchospasm, ↑secretions,

and respiratory depression

7. Examples of volatile liquids: fluothane, ethrane, & forane

8. gaseous agents: nitrous oxide

C. Adjuncts to general anesthesia – drugs that are added to an inhalation anesthetic other than IV

induction agent is an adjunct

1. Opioids are used preoperatively for sedation & analgesia, intraoperatively for induction &

maintenance of anesthesia, & postop for pain management.

a. They alter response to pain stimuli

b. If given close to the end of surgery, the residual analgesia often carries over in the PACU

This allows pt to awaken pain-free.

c. Examples: fentanyl, morphine-sulfate, & demerol

d. increase risk of respiratory depression – closely observe pt respiration & O₂ sat

e. Narcan is the drug used to reverse respiratory depression from opiates & it will reverse all

analgesic effects

2. Benzodiazepines are widely used for pre-medication before surgery for their amnestic effects, as

agents for the induction & maintenance of anesthesia, for conscious sedation, as supplemental

IV sedation during local & regional anesthesia, & for postop anxiety & agitation

a. Versed is the most commonly used benzo due to its shorter duration of aciton, amnestic

property, & absence of pain on injection

b. can be given IM or IV

c. can get respiratory depression with benzos

d. Flumazenil (romazicon) is the antagonist that may be used to reverse effects of benzos

(used as an antidote like narcan)

3. Neuromuscular blocking agents (muscle relaxants) are used as adjuncts to general anesthesia

to facilitate endotracheal intubations & to optimize the surgical working conditions by providing

relaxation & paralysis of skeletal muscles

a. neuromuscular blocking agents interrupt the trans. of nerve impulses at neuromuscular. jxn.

b. disadvantages of use of muscle relaxants is that the duration of their action may be longer

than the surgical procedure or reversal agents may not be completely effective & eliminated -

residual effects

Pt must be carefully observed so that their respiratory muscle movements & air patency good

Are they getting enough oxygen?

4. Antiemetics are used preoperatively, intraop, & postop. can be given with anesthesia

examples:

a. Zofran

b. phenergen

c. reglan

d. anapsin

Intraoperative Period

Intraoperative Period

I. Two main types of anesthesia: Anesthesia is classified according to the effect it has on the pt's CNS

& pain perception

A. Regional anesthesia: loss of sensation to a region of the body without loss of consciousness

when a specific nerve or group is blocked with administration of a local anesthetic

1. The pt may be given medication(s) to produce mild sedation or to relieve anxiety.

2. The nurse must avoid careless conversation, unnecessary noise, and unpleasant smells

which can be noticed by pt & cause OR experience to be negative

3. An example of regional: a. spinal., b. epidural., & c. peripheral nerve block

B. General anesthesia is the loss of sensation with loss of consciousness, skeletal muscle

relaxation, analgesia, and elimination of the somatic, autonomic & endocrine responses

including coughing, gagging, vomiting, & sympathetic NS responsiveness

1. General anesthesia is usually the technique of choice for pts having surgical procedures

a. that require significant skeletal muscle relaxation

b. last for long period of time

c. require awkward positions because of location of incision site

d. or require control of respiration

e. The client is extremely anxious & unable to have local or regional due to

contraindications or refuse

f. or if client is unable to remain immobile for long period of time. ie. head injury,

or intoxication

2. General anesthesia is most commonly administered by inhalation & to lesser extent by IV

3. An advantage to general anesthesia is the rapid excretion of the anesthetic agent &

prompt reversal of its effects when desired. It can be used with all age groups & any

type of surgery

4. Disadvantages of general anesthesia include risks associated with circulatory, respiratory,

hepatic, & renal side effects

a. If pt has a history of CHF or emphysema = greater risk for complications

b. Pts with hepatic & renal disorders can't excrete – liver not metabolize well

Wound classification based on color

Wound classification based on color – instead of extent of damage to tissues

1. this system can be applied to any type of wound that is healing by secondary intention

2. surgical wounds left open due to infection can be used with this system

3. sometimes wound can have two to three colors – go by most undesireable color

4. wound colors are red, yellow, and black

Red Wound

1. characteristics – traumatic or surgical wound, and wounds created surgically to allow for healing

2. possible serosanguinous drainage: pink to bright or dark red

3. healing chronic wound with granulation tissue present ie. skin tears, stage II pressure ulcers

4. wounds that are classified as clean with reepithelializing & granulating should be kept slightly moist & free from trauma to encourage healing

5. a dressing should be used that assists the wound with epithelialization

6. dressing can be used are transparent films or adhesive semi-permeable dressings

ie. Opsite, Tegaderm allow O₂ to get to wound

9. antimicrobials can be used such as bacitracin or neomycin if infection present

10. If there is an infection the wound usually covered with sterile dressing

11. You want to avoid unnecessary handling of the tissues during dressing change. don't want to

interrupt granulation (sensitive!)

Yellow wound has the presence of slough or soft necrotic tissue, liquid to semi-liquid, slough with exudate ranges from creamy / ivory to yellow / green

1. ideal place for bacteria to grow – must be removed

2. the wound is continuously cleansed to remove exudates & soft necrotic tissue

3. the wound is continuously cleaned – use absorbent dressing to pull excess drainage from wound

4. examples of this dressing are hydrogel & foam.

5. changes depend on amount of drainage

6. when you remove dressing, you should use saline or sterile water to wash wound

7. a hydrocolloid dressing such as duoderm – can be used for yellow wounds.

8. inner of portion of dressing combine with the exudates & form hydrating gel over wound

9. when the dressing is removed then the gel stays on the wound

10. the dressing is meant to be left in place for 7 days or until leakage that occurs around dressing

Black wound – covered with thick, dried black necrotic tissue also called escar

1. examples are full-thickness burns, pressure ulcers stage III – IV, & gangrenous ulcers

2. the more necrotic tissue that is present – greater risk of infection

3. immediate treatment is debridement

   a. can be surgically.

   b. mechanical – wet to dry dressing

   c. autolytic – ie. semi-occlusive or occlusive dressing

   d. enzymatic debridement – collagenase

   e. can use negative pressure wound therapy or vac pac – this uses suction to remove drainage & promote wound healing.

   f. hyperbaric oxygen therapy delivers oxygen at different atmospheric pressure

Factors delaying wound healing

1. nutritional deficiencies: protein, vit C, CHOs, zinc

2. inadequate blood supply slows the bloods ability to carry nutrients to the wound, not carry exudates away from wound & inhibit inflammatory response

3. corticosteroids impair phagocytosis by WBCs – depress formation of granulation tissue & inhibit wound contracture

4. infection

5. mechanical friction on wound

6. advanced age – slow collagen synthesis by fibroblast, impaired circulation requires longer time for epithelialization of skin & alters phagocytic & immune responses

7. obesity – ↓blood flow due to fatty tissue

8. diabetes mellitus

9. poor general health – generalized absence of factors necessary to promote wound healing

10. anemia↓O₂ at tissue level

Complications of healing – shape, location of wound are going to affect healing ability

1. hypertrophic scars & keloid formation occur when too much collagen tissue

   a. hypertrophic scar is improperly large, red, raised, & hard

   b. it does remain to the wound edges but becomes smaller over time

2. keloids are permanent. they have a larger protrusion of scar tissue that goes beyond wound edges & forms tumor-like mass

3. contracture is necessary for wound healing. it is abnormal for excessive contracture that cause malformation or contracture of skin or muscle.

   a. usually occurs if the injury is near a joint or in burns that involve large amounts of skin damage & loss

4. dehiscence is the separation of previously (primary healing) approximated wound

   b. infection caused by inflammation

   c. granulation tissue is weak & unable to hold up to stress applied to wound

   c. obese pts have increased risk due to poor wound healing

5. Evisceration can occur with dehiscence

   a. evisceration is when organs protrude through wound

   b. if this does occur you want to put on sterile saline water with sterile gauze

6. excess granulation occurs above wound surface

7. adhesions or bands of scars around organs can develop & lead to strangulation or necrosis of surrounding tissue

Anaphylaxis

Anaphylaxis

1. 1. acute systemic response that occurs in highly sensitive persons following injection of particular antigen (see pg 333 box13-1)

2. reaction begins within minutes of the exposure & can be simultaneous

Symptoms of anaphylaxis

1. feelings of uneasiness or foreboding

2. light headedness

3. itching palms & scalp

4. angioedema

5. edema of the uvula & larynx

6. pt may appear to be gasping for air, strider, wheezing, or barking cough

7. the respiratory effects can lead to death if not immediate interventions

Systemic Treatment

1. antihistamine – IV therapy benadryl

2. adrenaline – epinephrine can cause angina, restlessness, & taccycardia

3. bronchodilators – aminophylline

4. steroids – methyl prednisone, dexamethasone

5. hypotensives – dopamine

6. emergency O₂ – intubate

If you are administering drugs IV and pt shows anaphylaxis S&Sx

1. stop infusion immediately

2. stay with pt & hit call light

3. ask for medical support

4. maintain good IV line – ringer's lactate

5. place in supine position

6. take vitals every 2-5 minutes

7. administer emergency drugs as prescribed

8. maintain airway, give O₂

9. provide emotional support

Wound classification according to origin

1. surgical

2. non-surgical

3. know underlying cause of wound

4. acute

5. chronic

6. degree of tissue affected: burns

   a. superficial

   b. partial thickness

   c. full-thickness

Wound classification based on color – instead of extent of damage to tissues

1. this system can be applied to any type of wound that is healing by secondary intention

2. surgical wounds left open due to infection can be used with this system

3. sometimes wound can have two to three colors – go by most undesireable color

4. wound colors are red, yellow, and black

Diagnostic test for location & extent of inflammation

Diagnostic test for location & extent of inflammation

1. WBC with differential

2. erythrocyte sedimentation rate (ESR) or "sed rate"

3. C-reactive protein (CRP)

Medicines that deal with: infection, assist with affects, & destroy cause of inflammation

1. benadryl – antihistamine (blocks histamine)

2. Acetaminophen (Tylenol) will not reduce the of a inflammation process, but will aid in symptom relief and lower fever

3. antibiotics – destroy cause of inflammation

4. higher doses of NSAID's (aspirin)

5. for an acute hypersensitivity – corticosteroids (read nursing care Lemone 308-309)

Hypersensitivity is caused by an immune response by the body to an antigen that results in destruction to pt

1. if the antigen is exogenous – considered allergy

2. the body's response may be as simple as runny nose, itching at site, itchy eyes

3. it can be as serious as dyspnea, blood cell hemolysis,laryngeal spasms, angiodema localized tissue swelling: eyelids, lip, tongue, hands, feet, genitals

4. a hypersensitivity to latex: more common in healthcare workers – condom, balloons, rubberbands

5. a lot of people unaware that they sensitivity to latex until they get a rash which is apparent from exposure

6. recommendation of lemone is to use latex-free gloves – unless dealing with infections

7. the severity of a reaction to an allergen or antigen can be more severe with each exposure

8. other pts may be very sensitive to certain antigens & have more severe reactions each time

Tertiary Intention – known as "belated" primary intention

Tertiary Intention – known as "belated" primary intention

1. the wound may be left open to allow for granulation tissue to form & then be closed by sutures. ie contaminated wound

2. it also can be from a primary intention wound that has become infected & re-opened to allow granulation & then can be sutured

3. the scar is deep & wide

Causes of the inflammatory response

1. initiated by a particular agent

2. initiated by non-particular agent

3. exogenous agent

4. endogenous agent

Causes of inflammation

1. mechanical injuries – cuts, abrasions

2. physical injuries – burns

3. chemical injuries – toxins, poisons

4. microorganisms – viruses, fungi, or bacteria

5. temperature extremes – heat / cold

6. immunologic responses – hypersensitivity reaction

7. ischemic damage or trauma ie. stroke or MI

Cardinal signs of inflammation:

1. erythema

2. hyperemia

3. swelling due to accumulated fluid at the site

4. pain from tissue damage

5. chemical irritation of nerves

6. loss of function from swelling & pain

7. degree of functional loss will depend on site of injury & degree of injury

Signs of systemic manifestations:

1. temperature 100.4

2. pulse 90

3. respirations 20

4. WBC 12,000 or greater than 10% bands (10,000 leukocytes)

Basic types of inflammation

Basic types of inflammation are:

1. acute

2. subacute

3. chronic

Acute inflammation

1. the injury is healed in two to three weeks & most of the time no permanent damage occurs

2. the most prominent cell types are neutrophils

Subacute inflammation

1. consists of same appearance as acute

2. takes 2 wks to months to heal

Chronic inflammation

1. can last for months to years

2. it can start out when the acute inflammation is unable to remove foreign agent

3. the offending agent repeatedly injures tissue (s)

4. the most common cells are lymphocytes & macrophages

5. examples: rheumotoid arthritis (RA) & tuberculosis (TB )

6. process of continually having to fight the inflammation over extended time period can lead to immune dysfunction

Reconstruction – next phase of healing, has ability to intersect with inflammation phase

1. desired effect is that the tissue will be the same type & function as original tissue

2. simple resolution occurs when there is no devastation to the original tissue & body is able to successfully remove the cause

3. another type of resolution is "regeneration'

   a. the tissue is able to replace the original tissue with new tissue

   b. this varies by the type of tissue and cell type

   c. labile cells are able to restore themselves throughout life

*the cells are found where there is a constant change in the cells. ie. epithelial, bone marrow, mucous membranes, cervix, GI tract

d. stable cells continue to replace themselves until growing stops but they do have ability to

replace themselves if injury occurs

examples are osteocytes & parenchymal cells of kidneys, liver, & pancreas

Permanent or fixed cells

1. unable to replace themselves

2. when these cells are injured, they are replaced ("repair") with scar tissue

3. difference is tissue that has been repaired & can no longer function as it did previously

4. the wound is filled with scar tissue which provides tensile tissue strength

5. ie. nerve cells, skeletal muscles, cardiac muscle

Repair – more complex process that occurs by primary, secondary, or tertiary intention

1. primary intention

   a. occurs when the edges of the skin are well approximated

   b. wound is clean

   c. there is a small amount of tissue damage

   d. can occur naturally such as with a paper cut

   e. can occur with sutures

   f. glu (dermabond)

   g. staples (read stages of wound healing, pg 76 lemone)

2. secondary intention

   a. occurs when the wound has large, wide, jagged edges

   b. a lot of tissue damage

   c. these wounds can occur from trauma, infection, or ulceration

   d. inflammatory phase of the healing process may be more intense resulting in↑amount of

exudates, debris, & cells

e. this is where they might do I & D (irrigation & debridement)

f. this debris must be removed prior to healing

Primary Intention wound / incision becomes infected ie. splinter

1. wound will have to heal by secondary intention

2. wound heals from outer edges & from base to top & filled

3. because of the way it has to heal, greater amount of scar tissue results in larger scar

Types of Exudates

Types of Exudates

1. blister or pleural effusions will have serous exudates – primarily plasma & a few proteins

2. an injury that is moderate to severe has sanguineous fluid or hemorrhagic – has large # RBCs

3. a combination of serum & RBCs is called serosanguineous

As the plasma protein fibrinogen leaves the blood it is turned into fibrin, by products of injured cell tied into DIC

1. fibrin strengthens the clot that is formed by platelets

2. in the tissue it functions to trap bacteria, to prevent spread of bacteria, to serve as a framework for healing process

3. fibrinous exudate causes thick, sticky, meshwork of fibrinogen

Cellular Response – occurs less than 1 hr. after injury

1. blood flow through the capillaries is decreased due to fluid loss & thickness of fluid

2. leukocytes migrate to the inner surface of capillaries called "margination"

3. the lymphocytes move to the edge of the capillary wall & attach themselves – called "pavementing" - lemone p 293

4. after margination & pavementation have occurred then leucocytes leave blood & go into damaged tissues

5. the leukocytes are pulled into the injured tissue via "immigration" by chemotactic signals

6. Lemone states that the infectious agents, damaged tissues, & activated plasma substances ie.

   complement fractions, provide chemotactic signals that attract an army of neutrophils, monocytes, & macrophages at injury site.

7. Neutrophils are there first. The neutrophils are able to phagocytize bacteria & other damaged material

8. Lemone states neutrophils can digest 5-20 bacteria before they become inactivated or die

9. an accumulation of inactived neutrophils occurs

10. the bone marrow releases more neutrophils to keep up with ones inactivated or dead

11. these results in elevated WBCs (↑neutrophils)

When bone marrow not able to keep up with↑demand of neutrophils

1. immature neutrophils released into bloodstream

2. called "bands"

3. mature neutrophils are called "segmented neutrophils"

4. a "shift to the left" occurs when there are more bands than segmented neutrophils

5. healing is the last part of the inflammatory response

Inflammation: initial part of healing process

1. debridement occurs when particular matter, bacteria, damaged cells, & inflammatory exudates are removed by phagocytosis

2. this process sets wound for healing

3. nutrition is vital during inflammation process

4. leukocytes need the following: protein, glucose, O₂ for chemotactic, phagocytosis, & intracellular killings

5. diabetics are thought to have poor wound healing due to the small vessel disease which inhibits microcirculation &↓availability of O₂ to cells

6. glycosylated hemoglobin consumes O₂

7. the combination of the two further↓availability of O₂ to tissues

8. many of the symptoms of inflammation are produced by inflammatory mediators, histamines, kinins, & prostaglandins

Cardinal signs of inflammation (lemone) are: erythema, local heat caused by increased blood flow to the injured area, swelling due to accumulated fluid at the site, pain form tissue swelling, & chemical irritation of nerve endings & loss of function caused by swelling & pain

Cardiogenic – lemone 274 (learn the chart with manifestations)

Cardiogenic – lemone 274 (learn the chart with manifestations)

Heart's pumping ability is compromised to the point that it cannot maintain cardiac output & adequate tissue perfusion, cyanosis more prevalent,↑CVP, edema, fluid overload. * MI is primary cause

anterior wall of heart affected

cardiogenic shock leads to:

1. decreased cardiac contractility which leads to ↓l

2. decreased stroke volume & cardiac output which leads to ↓l

3. pulmonary congestion which leads to ↓l

4. decreased coronary artery perfusion which leads to ↓l

5. decreased cardiac contractility (creates cycle)

*treatment:

1. give O₂,

2. control chest pain (morphine a. dilates blood vessels, b. ↓preload, c.↓afterload, d.↓anxiety)

morphine is a vasoactive drug

Distributive

1. vasodilation &↓peripheral resistance (ability of vessels to contract & relax)

2. relative hypovolemia – body not really have low volume, but body thinks so due to vasodilation.

3. when you faint, this is distributive shock

4. precipitating event (infection etc)

5. vasodilation

6. activation of inflammatory response (↑capillary permeability – fluid seeps into tissue. if not treated, then pt really does lose fluid)

7. maldistribution of blood volume which leads to ↓

8. decreased venous return which leads to↓

9. decreased cardiac output which leads to ↓

10. decreased tissue perfusion

Septic – caused by widespread infection, most common type of distributive shock

1. leading cause of death in ICU

2. gram neg. bacteria. ie. E. coli; also some gram +

3. look for susceptible people: transplant pt, chemotherapy, elderly, very young, chronic illnesses, malnourished, invasive procedures

4. skin warm due to vasodilation ↑temp; later skin will be cold

5. blood clotting in capillaries will use up clotting factor, pt will get "DIC" - prone to bleeding

6. use APC – human activated protein will↓mortality in septic shock, anti-inflammatory, stimulates fibrinolysis, balances hemostasis between coagulation & anti-coagulation

7. nutrition needed also

Vasodilators

Vasodilators

1. Nitroglycerine (Tridil) & Nitroprusside (Nipride)

2. reduce preload (pressure when blood into heart- ↓ pressure) & afterload (heart has to pump against aorta), ↓O₂ demand of the heart

3. disadvantage: cause hypotension

4. given with cardiogenic shock

5. given with dopamine or dobutrex helps maintain BP

Vasoconstrictors (not used much) short-term, problem maintaining BP, will ↑BP

1. Norepinephrine (Levophed), Phenylephrine (Neo-Synephyrine), Vasopressin (Pitressin)

2. increase BP by vasocontriction

3. disadvantage: ↑afterload, thereby ↑workload of heart, compromise perfusion to skin, kidneys,

lungs, GI tract.

Other meds Lemone 277

1. diuretics ↑UO only when fluid replacement adequate

2. sodium bicarb – buffer

3. calcium

4. antiarrhythmics

5. broad-spectrum antibiotics – all invasive procedures

6. cardiogenic glycosides

7. corticosteroids

8. morphine

9. oxygen by mask, canula

10. Oxygen for 4-6 hrs then oxygen P0₂ 80 (best 90) perfusion 85. on ventilator if too low

Nutritional Support – need 3000 cal / day, will burn muscle in shock, helps GI to have food run thru it

1. Parenteral

2. Enteral – if in shock long time

   glutamine – ess. amino acid in stress – immunologic function in GI tract. fuel for lymphocytes

3. Stress ulcers – must be on something

a. H₂ inhibitors – pepcid, zantac

b. proton pump inhibitors - prevacid

Hypovolemic – lemone 273

1. caused by a ↓in circulating volume of 15% or greater (for 154 lbs pt, loss of 750-1300 ml / blood) this is 3 units of loss

2. external fluid loss – trauma, surgery, vomiting, diarrhea, diuresis, diabetes insipidus

3. internal fluid loss – hemorrhage, burns, ascites, peritonitis, dehydration, third space

4. progression: treatment is *prevention, correct underlying cause. ie with nausea give antiemetics

monitor blood glucose

Hypovolemic Shock leads to:

1. decreased blood volume which leads to↓

2. decreased venous return which leads to ↓

3. decreased stroke volume which leads to ↓

4. decreased cardiac output which leads to ↓

5. decreased kidney perfusion

*try to give packed red cells, give lactated ringers sol'n and .9 normal saline, elevate feet to↑BP

(this is called "shock position" or modified trendelenberg)