Types of cyanotic CHD

- Conditions with decreased pulmonary blood flow

1. TOF (tetralogy of fallot)

- Common in boys

- Problem:

a. pulmonic stenosis

b. overriding of aorta

c. right ventricular hypertrophy

d. ventricular septal defect

- Sx: boot shaped heart

- Frequent squatting/ Tets fell – due to hypoxic episodes because of decrease blood supply to the brain

- Syncope(fainting)

2. Truncus arteriosus

- Common in boys

- Problem: one major artery or trunk arises from the left and right ventricles in place of separate aorta and pulmonary artery

3. Transposition of the great vessels

- Common in boys

- Problem: aorta arises from the right ventricle instead of the left and pulmonary artery arises from the left ventricle instead of the right

4. Tricuspid atresia

- Tricuspid valve is completely closed allowing blood to flow from the right atrium to the right ventricle

General Management:

1. on oxygenation

- oxygen as ordered

- position in semi fowlers with neck slightly hyperextend or place in knee chest (squatting) position to relieve “Tets pell” (paroxysmal dyspnea with cyanosis relieved by squatting)

- digoxin as ordered to strengthen the contraction (+ inotropic effect) and slow down the heart rate ( - chronotropic effect)

2. on cardiac workload conservation

- promote rest (give pacifier)

- organize nursing activity

- avoid extremes of temperature

- diuretics as ordered (to reduce cardiac preload and workload)

3. on nutrition

- low Na formula (prevent fluid retention)

- limit feeding time (avoid tiring)

- monitor weight and rate of growth

4. Prevent infection
5. support coping and education of the family

Mitral Stenosis

- etiology: result from

o rheumatic heart disease/RHF

o atrial myxoma (tumor)

o calcium accumulation

- can lead to narrowing of valve opening due to thickening of the valve resulting from thrombosis, and calcification which may result to abnormal blood flow thus arising left atrial pressure, dilatation of left atrium, increased pressure from the pulmonary artery, and hypertrophy of the right ventricle

- S/Sx: asymptomatic

o But as valve narrows: dyspnea on exertion

· Orthopnea

· PND (paroxysmal nocturnal dyspnea

· Dry cough

· Hemoptysis

· Pulmonary edema

· Hypertension

· Hepatomegaly

· Pitting edema

· Dysrhythmias

Mitral Regurgitation

- Cause: RHF common in women

o Due to fibrotic and calcific changes it may lead to incomplete closure of the valve, then the blood will backflow to the left atrium thus resulting from insufficial mitral supply

Symptoms:

Fatigue

Weakness

Decrease cardiac output

Dyspnea

Chest pain

Palpitation

Progressive RSHF and LSHF

Atrial fibrillation

Normal BP

Systolic murmurs

Mitral Valve Prolapse

- Enlarge valvular leaflets protrudes into the left atrium during systole

- S/Sx:

Asymptomatic

Chest pain

Palpitation

Dizziness

Syncope

Ventricular dysrhythmias

Normal BP

Fatigue

General managemnt:

- vital signs

- administer oxygen supplement

- low Na diet

- give cardiac glycosides

digoxin (Lanoxin)

monitor:

· digoxin level: N: 0.5 – 2 ng/ml (more than 2 – toxic level)

· electrolytes: decrease K+ - prone to toxicity

· renal function test

inotropic action: increase contration of the heart

chronotropic action: decrease heart rate

advise to eat K+ food (dried fruits)

monitor apical pulse (PMI) – less than 60 hold the drug

antidote for toxicity: digoxin immune fab (Digibind)

- prepare for valve replacement

mechanical prosthetic valve

surgically done

Pre-surgery meds smooth induction of anesthesia

Pre-surgery meds smooth induction of anesthesia

1. Bicitra – renal failure, metabolic acidosis-don't want to vomit acid & aspirate – bronchospasm –

hard to tube & can close off airway = respiratory problems

2. Sleeping pill – make pt not so anxious

3. tranquilizer – ie. Valium (both a tranquilizer & antianxiety med)

4. sedative / hypnotic – Midazolam (Versed) #1 given to help pt to relax

5. anticholinergics – atropine sulfate, glycopyrrolate (Robinul) ↓secretions so not aspirate, amnesic

6. antiemetics – dolasetron mesylate (Ansemet), ondansetron hydrochloride (Zofran),

droperidol (Inapsine) for nausea – can cause respiratory depression

7. opiates – morphine, meperidine, fentanyl (these↑anesthesia induction, need ↓anesthesia drug)

8. antibiotics – cefazolin (Ancef) given 1 hr prior to surgery (total hip, total knee)

Additional Responsibilities

recording

transporting to OR

child – parent carries to OR

make sure talk to family where to wait, what time they'll be back, can page family in cafeteria,

family should not leave hospital

criteria

V/S stable

stand & walk

3 Things to ↓Incidence of Surgery Errors

1. ask pt prior to surgery what Dr. is doing (mark x on limb)

2. at holding in OR ask again "Which knee?"

3. in OR ask again (do "time out" and ask again, check ID band, check chart)

*count instruments before close

Preop Preparation Diet

Preop Preparation

Diet

1. NPO past midnight

2. empty water pitcher

3. not swallow H₂O after brushing teeth

Bowel prep.

1. go lytely

2. laxatives – dulcolax suppository

3. enemas – can get fluid deficit & vit K deficiency (no more than 3 enemas) ↑enemas is tiring

4. antibiotics – Neomycin, Kamtrex work on colon (not give bad diarrhea)

5. skin prep – clippers on surgery table

6. psychological preparation – use touch backrub, discuss fears, let pt make decisions to promote self worth, let children play beforehand

7. final preparation – may need to shave head (save hair & put in bag pinned to chart for wig), don't shave eyebrows

Preanesthetic Medication

On call

Purposes

Maalox, sodium citrate (Bicitra), cimetidine (Tagamet), famotidine (Pepcid), rantidine (Zantac),

meoclopramide (Reglan)

Barbituates / tranquilizers – secobarbital (Seconal), pentobarbitol (Nembutal)

Antianxiety – diazepam (Valium)

pt will forget some things prior to surgery (after surgery amnesia), warn about tests, time of surgery noted, bath before surgery – Hibiclens scrub 3x prior to surgery, use side rails to get up, turn to side, give sedation night before surgery (?), check pt ID band, take jewelry off & send home or lock up,

wigs off, pins in hair out, remove nail polish, teeth partials out, antiembolic stockings presurgery training

Elimination

Elimination

Hx of chronic constipation

last BM

diarrhea

signs of UTI

difficulty initiating a stream – older men

Activity

general muscle strength

limitation to walking, sitting, or moving in bed

Comfort

presence of discomfort (PCA pump – not all pain gone, but make pain tolerable)

perception of expected discomfort

knowledge of medicine routine

expectations regarding alleviation of postop pain

allergy Hx (latex, meds)

check for signs of liver / kidney dysfunction – med metabolism, anesthesia & adjunct drugs

Comfort

prior drug therapy

1. if pt on adrenal steroids, dx before surgery ↑susceptibility to infections, if remove too quickly,

can cause cardiovascular collapse

2. NSAIDs – dx one week prior to surgery, can ↑bleeding

diuretics (hydradiuril) – can get electrolyte imbalance & respiratory depression

3. erythromycin given with muscle relaxant can cause apnea & respiratory paralysis

4. valium – need to dx, can get stress & seizures

5. thorazine – interacts with anesthesia, causes hypertension

6. insulin – stress↑blood glucose, need to be on sliding scale, hold until Dr. order

7. MAO with anesthesia = hypertensive effects

8. coumadin ↑bleeding, (stop 3 days prior to surgery)

9. dilantin – give IV so not get seizure

alcohol intake

1. liver disease – bleeding tendency - ↓vit K, poor wound healing

2. poor nutrition

3. postop meds may be ineffective

may develop delirium tremens

Diagnostic Test MD may order

vary with hospital

40 – EKG, BUN, FBS

respiratory

Circulatory – CBC, electrolytes

renal

metabolic

Elderly Responses – physiologic changes compromise organ function & limit body's ability to adjust to stress

1. more than one chronic illness can ↑risk for postop complications

2. look at liver / kidney tests ie. electrolyte, creatinine, liver panel

3. risk for:

a. ↓ability to ambulate

b. disoriented – fluid & electrolyte imbalance

c. mind not as alert – need to orient as to where they are (reorient to room0

d. ↓fat = chill

e. ↑constipation

f. ↑skin tears / bruising

Nursing Diagnoses

anxiety: fear of death

risk for injury

Circulatory

Circulatory – (any history of heart disease?)

pulse – rate, rhythm, strength

heart sounds

circulation in extremities – skin color & temperature, capillary refill, strength of peripheral pulses

elderly – hx of MI or CHF or on digoxin – monitor serum K⁺ levels carefully (postop ↓K)

Nutrition

Wt to Ht ratio

presence of nausea & / or vomiting, diarrhea (NVD)

signs of dehydration

determine balanced diet

protein

vit C for wound healing

vit B – GI function & metabolism of CHO

vit K – clotting

*↑CHO, ↑protein, ↑calories *

Underweight

diminished reserves of CHO & fat for energy

protein used for energy – nitrogen imbalances

decreased protein for healing – wound separation & infection

can use hyperalimentation for deficiencies

Obese

respiratory complications

V/S fluctuations

wound separation & infection

incisional hernias

thrombophlebitis

complications of anesthesia

fatty tissue lacks circulation

abdominal pain due to pressure, pt can't breathe properly

can't move well, can get thrombophlebitis under anesthesia

1. harder to access – cut through more fat

2. anesthesia stored in adipose tissue – absorbed readily & take ↑anesthesia to put pt to sleep

3. take longer to get over it, anesthesia released from adipose slowly over time

Physiological Response

Physiological Response - caused by:

Anxiety – for some it is so high, they can't cope

Lack of emotional response – can't express, can be angry, resentful, confused, depressed, vulnerable

to psychiatric reaction, denial, (moderate anxiety is good helps you study/perform well on exams)

Common fears & concerns

1. fear of unknown (primary one) can take pt to recovery room before surgery to meet nurses, tell pt

what to expect

2. fear of malignancy

3. fear of anesthesia ("truth serum")

4. loss of control – not able to bear pain

5. disfigurement / disability (paralyzed)

6. sex loss

7. job security

8. insurance limits

9. disruption of life pattern (family care ♀ )

Voluntary & Informed Consent (LeMone pg. 55-56)

voluntary – not persuaded or coerced in any way

informed – Dr. responsible for giving info & explaining to pt about surgery

consent – need a witness (nurse frequently)

diagnostic procedure – anything with sedation needs consent

if not have surgery – what consequences are (complications & changes in body function)

Criteria for informed consent (*nurse needs to get signed consent form*)

nature of the procedure to be performed

available options

risks & benefits associated with each option

time alloted for questions

pt may withdraw at any time – up to anesthesia administration time

Voluntary & Informed Consent - con't

physician & nurse responsibilities

minor or incompetent can't sign – need legal guardian to sign

emancipated minor (married, or earning own livelihood & keeping earnings can sign)

parenthood – parenthood does not emancipate you

next of kin – can't have girlfriend / boyfriend sign unless have a POA in writing & notarized

emergency – children can get treatment (child in intensive care – Dr. can get court order & go

against parents

can do a 3-way call & Dr. & nurse sign in emergency

check mark (for illiterate person) must be witnessed by two witnesses

pt can't sign consent once sedative given

Assessment

knowledge of events

psychological readiness

physiological status

Patient Knowledge

past surgical experience – what type

understanding of proposed surgery - "Tell me what Dr. told you about surgery."

knowledge of preop events – diagnostic tests

knowledge of postop events – going to PACU

knowledge of exercises to be carried out – deep coughing, teach before surgery, incentive spirometry

Psychological readiness – degree of anxiety, let Dr. talk to them if anxiety severe

Subjective

concerns or fears about surgery

usual coping methods

cultural / religious beliefs & practices – call chaplain or offer to pray

support system – family & close friends

changes in sleep patterns

urinary frequency

Sympathetic Nervous System

Response Positive Negative

vasoconstriction maintain BP & adequate bloodflow to

heart & brain

increased cardiac output maintain BP

decreased GI activity anorexia, gas pains,

constipation

Hormonal

Response Positive Negative

↑glucocorticoid secretion (adrenal cortex) ↑ blood volume K⁺ loss

Na⁺ retention (post surgery need KCL)

protein & fat catabolism ↑energy (amino acids available for healing) N⁺ loss = weight loss

urea & N⁺ excreted in urine

negative N⁺ balance

↑platelet production prevent bleeding through clotting possible thrombus formation

wear TED hose

↑ADH secretion (posterior pituitary) increased blood volume possible fluid overload

elderly susceptible (COPD)

EBL = estimated blood loss

Degree of Urgency

Degree of Urgency

1. emergency – immediate attention, life threatening ie. bleeding, intestinal obstruction, gunshot,

stab, extensive burns

2. urgent – prompt attention (24-30 hrs) ie. acute GB or ureteral stones

3. required – pt needs to have operation (few wks. to months) ie. prostatic hyperplasia without

bladder obstruction, thyroid, cataracts

4. elective – failure to have not catastrophic, but should be operated upon ie. stress incontinence,

repair scars, hernia simple, vaginal repair

5. optional – decision rests with pt. (personal preference) – ie. cosmetic surgery – nose job

1. diagnostic – determine or confirm cause of symptoms. ie. lymph node biopsy, check for Hodgkins

disease exploratory laparotomy (rare), bronchoscopy, breast biopsy

2. curative – removal of a diseased part appendectomy or excision of a tumor

3. reparative – rejoin a separated area. ie. mend a multiple stab wound

4. restorative – strengthen weakened area, correct deformities. ie. herniorrhaphy, mitral valve

replacement

5. palliative – relieve symptoms without curing the disease – rhizotomy (cut nerve root to ↓pain),

sympathectomy (cut nerve that controls HCL production, usually control of HCL is with meds)

6. cosmetic – improve appearance – plastic surgery

A. constructive – cleft palate

B. reconstructive – graft after burn

7. ablative – remove diseased tissue, organ, or extremity, ie. amputation, appendectomy, excision of

tumor, colon resection,

8. transplantation - replacement of organs / structures ie. kidney, liver, cornea, heart, joints

Marshall Marchetti Krantz (surgery named after Dr.) - bladder tucks

Suffixes

1. ectomy – removal of an organ or gland ie. hemorrhoidectomy, appendectomy, cholecystectomy

2. orrpaphy – suturing or stitching ie. herniorrhaphy – intestines can drop through

3. ostomy – providing of a permanent opening (stoma) colostomy (colon)

4. otomy – cutting into or incision of ie. tracheotomy

5.plasty – plastic repair ie. rhinoplasty

6.oscopy – looking into ie. bronchoscopy, endoscopy

Effects of Surgery on the Patient

1. physiological & psychological

2. stress reaction or response (normal)

3. psychological response not directly related to type of surgery ie. some patients are very stressed

about a (minor) mole removal on face, others don't seem stressed about (major) surgery

have pt talk through this

Physiologic Responses – compensatory mechanisms

sympathetic nervous system – activated due to stress

hormonal response – endocrine

these act to protect the body when stress is too great, or blood loss is severe (body will go into shock)

Surgery Outline

Perioperative phase (pre-surgery)

begins as soon as decision is made for surgery

ends when transfer to OR

Intraoperative phase (while in surgery)

Postoperative phase (admitted to PACU – post anesthesia care unit)

ends with complete recovery

※most insurance will pay for 10 days post-op for minor surgery

and 90 days post-op for major surgery (includes Dr. visit on both)

10 days to 2 wks to remove sutures

Nurses Function – assess, teach, report(*see chart in LeMone pg 54 – classifications of surgery)

1. Assist pt

A. cope with stressors – help pt to express fears ie. fears of pain from surgery & post surgery

B. seek relief from pain

C. return to optimal functioning

2. Primarily responsibility & accountability for nursing care of client having surgery is to

A. assess pt

B. report complications

Classified

1. location – external or internal, location of body part

2. extent or risk factor

3. purpose of the surgery

4. degree of urgency

*can get internal scars – adhesions can cut off circulation

*laproscopic procedure↓ adhesions

Location

1. external or internally

2. location of body parts or systems

A. cardiovascular

B. chest – heart, lung

C. neurologic – nervous system

Extent

1. minor (usually outpatient) – laprascopic – minimal physical assault or risk ie. skin lesion, D&C

pt can still have concerns with minor procedure (ie. cataract)

2. major (inpatient) – extensive physical assault / risk ie. joint replacement, heart surgery