Chapter 1 Medical Surgical Nursing
Medical-surgical nursing- health promotion, health care, and illness care of adults based on knowledge derived from the arts and science and shaped by knowledge (the science) of nursing.
Focuses on adult client’s response to actual or potential alterations in health
Client- based on a philosophy that individuals are active participants in health and illness as well as consumers of healthcare services
National Academy of Sciences proposed a set of five core competencies that all healthcare professionals should possess, regardless of their discipline. They are based on using communications, knowledge, technical skills, critical thinking, and values in clinical practice. (Table 1-1; pg 5)
Provide client-centered care Work in interdisciplinary teams Use evidence based practice Apply quality improvement
Critical thinking- thinking about one’s own thinking. It is self-directed that is focused on what to believe or do in a specific situation. Consider:
Purpose of thinking
Your level of acquired knowledge Prejudices that may influence thinking Information that is needed from other sources Ability to identify other options
Personal values and beliefs Critical thinking skills
Divergent thinking- having the ability to weigh the importance of information (abnormal data are usually considered relevant, normal data are helpful but may not change the care you provide)
Reasoning- having the ability to discriminate between facts and guesses
Clarifying- noting similarities and differences to sift out unnecessary information to help focus on the present situation
Reflection- comparing different situations with similar solutions
The nursing process benefits nurses who provide care, clients who receive care, and setting where care is provided. The five steps or phases in the nursing process are assessment, diagnoses, planning, implementation, and evaluation. (Table 1-2; pg 7)
Outcomes of planning should be mutually established by the client and the nurse. Outcome criteria are client centered, time specific, and measurable; they are classified into three domains which are cognitive (knowing), affective (feeling), and psychomotor (doing).
Code of Ethics – one criterion that defines a profession (Box 1-2; pg 11)
Ethics- principles of conduct concerned with moral duty, values, obligations, and the distinction between right and wrong.
Standard- statement or criterion that can be used by a profession and by the general public to measure quality of practice (Box 1-3; pg 11)
Dilemma- choice between two unpleasant, ethically troubling alternative
Advance directive- living will, a document in which a client formally states preferences for health care in the event that he or she later becomes mentally incapacitated
Culturally sensitive nursing (Box 1-4)
Roles of the nurse in medical surgical nursing practice
Leader and manager
Case management- focuses on management of a caseload (groups) of clients and the members of the healthcare team caring for those clients. The purpose is to maximize positive outcome and contain costs
Delegation- carried out when the nurse assigns appropriate and effective work activities to other members of the healthcare team; the nurse retains the accountability for the activities performed by other nurses.
Critical pathway- healthcare plan designed to provide care with a multidisciplinary interventions, including education, discharge planning, consultations, medication administration, diagnosis, therapeutics, and treatments
Quality assurance- consists of the quality control activities that evaluate, monitor, or regulate the standard of services provided to the consumer
Chapter 2 (Blue Book)
Health and Illness in the Adult Client
Health- as a state of complete physical, mental, and social well being and not merely the absence of disease or infirmity.
The Health-illness continuum represents health as a dynamic process, with high level wellness at one extreme of the continuum and death at the opposite extreme. (Look at figure 2-1)
Holistic health care- is when all aspects of a person (physical, psychosocial, cultural, spiritual, and intellectual) are considered as essential components of individualized care.
Factors affecting Health
Genetic Makeup- affects personality, temperament, body structure, intellectual potential, and susceptibility to the development of hereditary alterations in health.
Cognitive Abilities and Educational Level- although cognitive abilities are determined prior to adulthood, the level of cognitive development affects whether people view themselves as healthy or ill; cognitive levels also may affect health practices.
Race, Ethnicity, and Cultural Background- Certain diseases occur at a higher rate of incidence in some races and ethnic groups than in others. The ethnic and cultural background of an individual also influences health values and behaviors, lifestyle and illness behaviors.
o Ex. Hypertension is more prevalent among African Americans, TB and diabetes is more common among Native Americans, eye problems among Chinese Americans.
Age, Gender, and Developmental Level
Lifestyle and Environment- The components of a person’s lifestyle that affect health status include patterns of eating, use of chemical substances (alcohol, nicotine, caffeine, legal and illegal drugs), exercise and rest patterns and coping methods.
Socioeconomic Background-Both lifestyle & environment influences are affected by ones income level. The culture of poverty, which crosses all racial & ethnic boundaries, negatively influences health status.
Geographic Area- the geographic area in which one lives influences health status. Health Promotion and Maintenance (Box 2-1)
Eat three balanced meals a day Exercise moderately and regularly Sleep 7 to 8 hours each day
Limit alcohol consumption to a moderate amount and favor red wine.
Keep sun exposure to a minimum.
Maintain recommended immunizations (Table 2-1) Disease and Illness
Disease and Illness are terms that are often used interchangeably, but in fact they have different meanings. Disease- a medical term describing alterations in structure and function of the body or mind. Diseases may have
mechanical, geologic, are normative causes.
o Mechanical causes of disease result in damage to the structure of the body and are the result of trauma or extremes of temperature.
o Biologic causes of disease affect body function and are the result of genetic defects, the effects of aging, infestation & infection, alterations in the immune system, & alterations in normal organ secretions.
o Normative causes are psychologic but involve a mind body interaction, so that physical manifestations occur in response to the psychologic disturbance.
Chronic- a disease that is has one or more of these characteristics: 1) Is permanent 2) leaves permanent disability 3) causes nonreversible pathophysiology 4) requires special training of the client for rehabilitation, 5) requires a long period of care; usually characterized by periods of remission and exacerbation.
Remission- the person does not experience symptoms even though the disease is clinically present. Exacerbation- the symptoms reappear
Communicable- a disease that can spread form one person to another Congenital- a disease or disorder that exists at or before birth
Degenerative- a disease that results from deterioration or impairment of organs or tissues
Functional- a disease that affects fxn or performance but does not have manifestations of organic illness Malignant- a disease that tends to become worse and cause death
Psychosomatic- a psychologic disease that is manifested by physiologic symptoms Idiopathic- a disease that has an unknown cause
Iatrogenic- a disease that is caused by medical therapy
Illness- is the response a person has to a disease; response is highly individualized
Illness behaviors- the way people cope with the alterations in health and function caused by disease; are highly individualized and are influenced by age, gender, family values, economic status, culture, educational level, and mental status.
A sequence of Illness behaviors :
Experiencing symptoms- The most significant manifestations is pain.
Assuming the sick role- The person usually validates this belief with others and seeks support for the need to have professional treatment or to stay at home form school or work.
Seeking medical care- People who believe themselves’ to be ill and who are encouraged by others to contact a healthcare provider
Assuming a dependent role- this begins when a person accepts the diagnosis and planned treatment of the illness. It is in this stage that the person may enter the hospital for treatment and care.
Achieving recovery and rehabilitation- the person now gives up the dependent role and resumes normal roles and responsibilities. As a result of education during treatment and care, the person may be at a higher level of wellness after recovery is complete.
The response of the person to the illness is influenced by the following factors: The point in the life cycle at which the onset of the illness occurs The type and degree of limitations imposed by the illness
The visibility of impairment or disfigurement The pathophysiology causing the illness
The relationship between the impairment and functioning in social roles Pain and fear
Things to do if the patient has a chronic illness. Live normally as possible
Learn to adapt activities of daily living and self care activities
Grieve the loss of physical function and structure, income, status, roles, and dignity Comply with a medical treatment plan
Maintain a positive self-concept and a sense of hope. Maintain a feeling of being in control
Confront the inevitability of death. Illness Prevention
Primary Prevention- includes generalized health promotion activities as well as specific actions that prevent or delay the occurrence of a disease.
o Ex: Protecting oneself against environmental risks, such as air and water pollution, eating nutritious foods, sunscreen, seat belts, practicing safe sex, immunizations.
Secondary Prevention-involves early diagnosis and treatment of an illness that is already present, to stop the pathologic process and enable the person to return to their former state of health as soon as possible.
o Ex: Having screenings for diseases such as hypertension, diabetes mellitus, and glaucoma, obtaining physical exams and diagnostic tests for cancer, performing self examination for breast or testicular cancer, TB skin tests
Tertiary Prevention- This level focuses on stopping the disease process and returning the affected individual to a useful place in society within the constraints of any disability.
o Ex: Obtaining medical or surgical treatment for an illness, enrolling in specific rehab programs, joining work training programs following illness or injury
Meeting health needs of adults (tables 2-4, 2-5, 2-6, and 2-7 and boxes 2-3, 2-4, 2-5).
The adult years are divided into three stages: the young adult (ages 18 to 40), the middle adult (ages 40 to 65) and the older adult (over 65).
The young adult 18 to 25, the healthy young adult is at the peak of physical development. Risks for alterations in Health
The young adult is at risk for alterations in health form accidents sexually transmitted diseases, substance abuse, and physical or psychosocial stressors.
The middle adult is at risk for alterations in health from obesity, cardiovascular disease, cancer, substance abuse, physical stressors.
The older adult has problems with hypertension, arthritis, heart diseases, cancer, sinusitis, pharmacologic effects, physical and psychosocial stressors and diabetes. The risks for injury in older adults are also at risk for falls, fires, and motor vehicle crashes.
Chapter 4- Blue Book- The Surgical Client
Surgery- an invasive medical procedure performed to diagnose or treat illness, injury, or deformity. Invasive- any procedure that goes inside the body cavity, breaks the skin; ex surgery, catheter, etc… Perioperative period- the total surgical episode
Preoperative period- begins when the decision for surgery is made and ends when the client is transferred to the operating room
Intraoperative period- begins when the client enters the operating room and ends with admitted to the postanesthesia care unit(PACU), or recovery room
Postoperative period- begins with the clients admitted to the PACU and ends with the clients complete recovery from the surgical intervention
Ambulatory Surgery- have surgery and leave in the same day Classification of Surgical Procedures:
o Diagnostic- determine or confirm a diagnosis; breast biopsy, bronchoscope o Ablative- remove diseased tissue, organ, or extremity; appendectomy, amputation o Constructive- build tissue/organs that are absent; repair of cleft palate
o Reconstructive- rebuild tissue/organ that has been damaged; skin graft after a burn, total joint replacement o Palliative- alleviate symptoms of a disease(not curative); bowel resection in client with terminal cancer o Transplant- replace organs/tissue to restore function; heart, lung, liver, kidney transplant
o Cosmetic- face lift, breast augmentation Risk Factor:
o Minor- minimal physical assault with minimal risk; removal of skin lesions, dilation and curettage, cataract extraction
o Major- extensive physical assault and/or serious risk; transplant, total joint replacement, colostomy Urgency:
o Elective- suggested, though no foreseen ill effects if postponed; cosmetic surgery
o Urgent- necessary to be performed within 1 to 2 days; heart bypass, amputation b/c of gangrene, fractured hip o Emergency- performed immediately; obstetric emergencies, bowel obstructions; life threatening trauma
Assessments before Surgery:
Age, nutrition, obesity, immunocompetence, fluid and electrolyte imbalances, pregnancy Previous surgeries
Client misperceptions Medication history Allergies
Smoking habits, alcohol, substance abuse- reacts with anesthesia Family support- for rehab
Occupation- may have to take off work to recover
Preoperative pain- document how much pain in before and then after Emotional health
Culture- very important b/c ppl view pain differently Client expectations
Physical Assessment: General survey Head and neck Integument Thorax and lungs
Heart and vascular system Abdomen
Diagnostic tests- provide baseline data or reveal problems that may place the client at additional risk during and after surgery
Trend of shorter hospital stays = studies and procedures are performed in a preadmission clinic within a week prior to elective surgery
Most commonly performed preoperative lab tests- Complete blood counts, electrolyte studies, coagulation studies, and urinalysis
Hemoglobin and Hematocrit-
o Increased- dehydration, excessive fluid plasma loss, polycythemia vera o Decreased- fluid overload, excessive blood loss, anemia
o Nursing implications- monitor oxygenation, I&O, vital signs, assess for bleeding WBC count-
o Increased- infectious/inflammatory processes, leukemia o Decreased- inadequate glucose intake in relation to insulin o Nursing Implications- inflammation, temp, pulse
Electrolytes- KNOW VALUES!
Look at pg 943 in KOZIER TEXT!!! (also look in blue book)
X-rays- older clients with risk factors related to heart and lung function; provides baseline info about the size, shape, and condition of the heart and lungs
ECG- electrocardiogram; ordered for clients undergoing general anesthesia when they are 40 years of age or have cardiovascular disease
Creatine clearance- best indicator of renal function CBC- see if it is ok to lose any amount of blood Serum electrolytes and creatine- know normal ranges Coagulation studies- see if patient clots normally BUN levels
Glucose, UA, HCG-human chorionic gonadotropin Look at Nursing Diagnoses on pg 70 in blue book!
Client teaching- the most important part of postoperative phase
Client expectations, what they will experience- nurse needs to listen to client and identify concerns and fears Psychosocial support to reduce anxiety
Tell the client the roles of each person involved- client and family during each phase of procedure Skills training- moving, deep breathing, coughing, splinting, or incentive spirometer
Box 37-4 pg 945 Kozier text!
Informed Consent- disclosure of risks associated with the intended procedure or operation to the client, and includes a legal document required for certain procedures and surgeries
Need for the procedure in relation to the diagnoses Description and purpose of the proposed procedure Possible benefits and potential risks
Likelihood of a successful outcome
Alternative treatments or procedures available Anticipated risks
Physician’s advice as to what is needed Right to refuse treatment or withdraw consent
o The nurse can discuss this information with the client
o If the client has concerns , the surgeon is responsible for supplying further information Perioperative Risk Factors
1) Verifying the procedure
2) Physically marking and initializing the site
3) Taking a “Time Out” before starting any procedure- To ensure the right procedure will be performed on the right client on the correct site with the necessary and correct healthcare providers there- This is all done BEFORE the patient is anesthetized
A complete medication history- OTC, RX, and herbals
Anticoagulation medications should be discontinued before surgery- prevent excessive blood loss during surgery Hyperthermia and hypothermia are risks
o Warm blankets
o Limit amount of exposed skin
o Prevent surgical drapes from becoming wet o Adjust room temp to normal
o Monitor clients temp and avoid over heat o Use heat maintenance devices
o Warm irrigation or infusion solutions o Humidify airway
*In Diabetic clients, the stress of surgery increases blood sugar* Immediate Care: PACU
Care begins when client has been transferred from operating room to the PACU.
PACU nurse monitors VS and surgical site to determine response to procedure and detect significant changes. They also assess mental status and orient X3, evaluate Input and Output, and pain level
PACU nurses also offer emotional support which is essential b/c client is vulnerable
Inform the floor nurse about client's condition and any post-op orders prior to client arrival back to their room. Post-OP head to toe assessment includes:
o General appearance o VS
o Emotional status o Quality of respirations o Skin Color & Temp o Pain level
o type of IV fluids and flow o Dressing site
o Drainage on dressing or bed o Urinary output
o Ability to move all extremities
After major surgery the nurse generally asses client every 15 min during first hour & once stable every 30 for about 2 hours and then every 4 hours
Ensure clients safety
SHOCK -life threatening b/c of insufficient blood flow to vital organs, inability to use oxygen and nutrients, inability to rid waste
o Hypovolemic shock is most common and results from decrease in circulating fluid volume from blood or plasma loss
o excessive blood loss
o a concealed is internally from blood vessel that’s not sutured/cauterized or drainage tube that has eroded the vessel
o Obvious hemorrhage is externally from a dislodged or ill-formed clot at the wound. o hemorrhage may occur b/c of abnormalities in blood's clotting
o hemorrhage from a vein oozes quickly & is dark red, arteries its bright red spurts of blood pulsating w/ each beat
o Nursing Care for hemorrhage is stopping the bleeding, replenishing blood volume,
care for shock and apply pressure with either gloved hand or applying one or more sterile gauze pads Prepare the client and family for emergency surgery all depending on the severity.
Deep vein thrombosis
o blood clot associated with inflammation in deep veins; usually occurs in lower extremities
o may result from trauma during surgery, pressure under knee, or sluggish blood flow during and after surgery o clients most at risk are over 40 and:
have had orthopedic surgery to lower extremities; urologic, gynecologic, or OB surgeries, or neurosurgery have varicose veins
history of thrombophlebitis or pulmonary emboli are obese
have an infection have a malignancy o common assessment findings
pain or cramping in calf or thigh
redness edema of entire extremity with slightly elevated temp
may have positive Homan's sign (pain in calf on dorsiflexion of the affected foot) o Nursing care for DVT
focuses on preventing a portion of clot from dislodging and becoming an embolus to heart, brain, or lungs preventing other clots from forming
supporting the client's own physiologic mechanism for dissolving clots
Admin anticoagulants as prescribed (NSAIDs not usually given with these b/c it increase affect) monitor lab values for clotting time
maintain bed rest and keep affect extremity at or below heart apply thigh-high antiemboli stocking or device
ensure affected area is not rubbed or massaged apply heat as prescribed
Record bilateral calf or thigh circumference and asses color and temp every shift. Pulmonary embolism
o A dislodged blood clot or other substances that lodges in a pulmonary artery. o common assessment findings in client with pulmonary embolism include:
mild to moderate dyspnea chest pain
diaphoresis anxiety restlessness
rapid respirations and pulse dysrhymias
o Nursing care for embolis
Stabilize respiratory and cardiovascular functioning while preventing formation of additional emboli is most imp.
frequently assess and record general condition and VS maintain client on bed rest and keep head of bed elevated provide oxygen as ordered and monitor pulse oximetry
admin prescribed IV fluids to maintain balance while preventing fluid overload maintain comfort by administering analgesics and sedatives
Respiratory Post-OP Complications Pneumonia
o Inflammation of lung tissue caused by either microbial infection or foreign sub. In lung that causes infection. o Factors that may be involved in development
retained pulmonary secretions failure to cough deeply impaired cough reflex decreased motility
o Common assessment findings of post-op client with pneumonia high fever
rapid pulse and respirations chills (may be present initially)
productive cough (may be present depending on the type of pneumonia) dyspnea
crackles & wheezes o Goals in nursing care
treat the infection
support respiratory effects promote lung expansion preventing organisms spread o Nursing care for pneumonia
obtain sputum specimen for C & S testing position client with head of bed up
encourage the client to turn, cough, and perform deep breathing exercises at least every 2 hours assist with incentive spirometry, intermittent positive pressure breathing and/or nebulizer treatment ambulate client as condition permits
admin oxygen as ordered
asses VS, breath sounds, and general condition
Maintain hydration to help liquefy pulmonary secretions administer antibiotics, expectorants, antipyretics, and analgesic provide or assist with frequent oral hygiene
prevent spread of microorganism by teaching proper disposal of tissues, cover mouth when coughing, and good hand washing
o incomplete expansion/collapse of lung tissue resulting in inadequate ventilation & retention of pulmonary secretions
o Common Assessment findings: dyspnea
diminished breath sounds over affected area anxiety and restlessness
o Nursing Care for atelectasis: position head of bed up admin oxygen as prescribed
encourage coughing, turning, and deep breathing every 2 hours ambulate the client as condition permits
Assist with incentive spirometry or other pulmonary exercises such as inflating a balloon, as ordered. promote hydration
Wound Post-OP Complications
Common assessment findings of infected wounds: o pain
o purulent odorous discharge o redness
o warmth o tenderness
o edema around the edges of incision o fever
o increased respiratory and pulse rates Nursing Care for wounds:
o prevent and monitor for complications
o support healing process, provide emotional support, teach wound care o maintain medical asepsis
o follow CDC guidelines for wound care
o Observe aseptic technique during dressing change and handling of drains and tubes o asses VS, especially temp
o evaluate characteristics of wound discharge (COCA)
o asses condition of incision (approximation of edges, sutures, staples, or drains)
o Clean, irrigate, and pack wound in prescribed manner. Sterile NS is often prescribed iodine is not recommended
o maintain hydration and nutritional status o culture wound prior to beginning antibiotics Dehiscence- separation in layers of incise
onal wound- cover wound with sterile dressing moistened with NS immediately Evisceration- protrusion of body organs from a wound dehiscence
Primary intention healing
o When the wound is uncomplicated and clean and has sustained little tissue loss.
o The edges are well approximated (come together well) with sutures, staples or superglue. o heal quickly and have very little scarring
Secondary intention healing
o When wound is large, gapping, and irregular.
o tissue loss prevents wound edges from approximating o granulation tissue fills the wound
o takes longer to heal, more prone to infection, and develops more scar tissue Tertiary intention healing
o when enough time passes before a wound is sutured o infection likely to take place
o wound edges are not approximated
o tissue is regenerated by granulation process o closure results in big scar
stages of wound healing
o All wounds heal in four stages
o Healing time varies according to age, nutritional status, general health, and type and location of wound Stage 1 (from surgery thru day 2)
Stage 2 (day 3 thru day 14) Stage 3 ( day 15 thru week 6)
Stage 4 (several months to a year following surgery) **Look on pg 76 for complete description if needed Post-OP Complications associated with Elimination
o may occur as result of recumbent position,
effects of anesthesia or narcotics,
inactivity, altered fluid balance, nervous tension, surgical manipulation in pelvic area
o Nursing Care for urinary retention: promote normal urinary elimination asses for bladder distention
asses amount of urine in bladder with portable ultrasound scanner(non-invasive to see if catheter is needed)
monitor input and output
Maintain IV infusion if prescribed
Increase daily oral fluid intake to 2500-3000 ml if condition permits insert straight or indwelling catheter if ordered
Promote normal urinary elimination by: -assisting & providing privacy with bedpan -help to BSC
-assist male to stand to void
-pour a measured amt of warm water over perineal area (if they pee, subtract amt of water from total amt) Bowel elimination
o may occur as result of general anesthesia narcotic analgesia decreased motility
altered fluid and food intake during pre-op period o Nursing Care for normal bowel function
Asses for return of normal peristalsis
auscultate bowel sounds every 4 hours while client is wake asses abdomen for distention
determine if client is passing flatus
monitor for passage of stool, including amount and consistency encourage early ambulation within prescribed limits
facilitate a daily fluid intake of 2500-3000 ml (unless contraindicated) provide privacy
if no BM has occurred within 3-4 days after surgery a supp or enema may be ordered **Special Considerations for older adults Pg 79 chart
Chapter 35 (old book)
medication- a substance administered for the diagnosis, cure, treatment, or relief of a symptom or for prevention of disease; used interchangeably with the word drug
drug- also has the connotation of an illicitly obtained substance such as heroin, cocaine, or amphetamines; crude drugs: opium, caster oil, and vinegar (used in ancient days)
prescription- written direction for the preparation and administration of a drug
generic name- given before a drug becomes officially an approved medication; used throughout the drug’s use official name- the name under which it is listed in one of the official publications (ex: United States Pharmacopeia) chemical name- the name y which a chemist knows it; describes the constituents of the drug precisely
trade name- the name given by the drug by the drug manufacturer; the name usually selected to be short and easy to remember; aka: brand name
pharmacology- the study of the effect of drugs on living organisms pharmacy- the art of preparing, compounding, and dispensing drugs
pharmacist- prepares the drug; person licensed to prepare and dispense drug and to make up prescriptions clinical pharmacist- specialist who often guides the physician in prescribing drugs
pharmacy technician- a member of the health team who in some states administer drugs to clients Type of Drug Preparations
Aerosol spray or foam- a liquid, powder, or foam deposited in a thin layer on the skin by air pressure Aqueous solution- one or more drugs dissolved in water
Aqueous suspension- one or more drugs finely divided in a liquid such as water Caplet- a solid form, shaped like a capsule, coated and easily swallowed
Capsule- a gelatinous container to hold a drug in powder, liquid, or oil form Cream- a nongreasy, semisolid preparation used on the skin
Elixir- a sweetened and aromatic solution of alcohol used as a vehicle for medicinal agents Extract- a concentrated form of a drug made from vegetables or animals
Gel or jelly- a clear or translucent semisolid that liquefies when applied to the skin
Liniment- a medication mixed with alcohol, oil, or soapy emollient and applied to the skin Lotion- a medication in a liquid suspension applied to the skin
Lozenge (troche)- a flat, round, or oval preparation that dissolves and releases a drug when held in the mouth Ointment (salve, unction)- a semisolid preparation of one or more drugs used for application to the skin and
Paste- a preparation like an ointment, but thicker and stiff, that penetrates the skin less than an ointment Pill- one or more drugs , mixed with a cohesive material, in oval, round, or flattened shapes
Powder- a finely ground drug or drugs; some are used internally, other externally
Suppository- one or several drugs mixed with a firm base such as gelatin and shaped for insertion into the body (ex: the rectum); the base dissolves gradually at body temperature, releasing the drug
Syrup- aqueous solution
Tablet- a powdered drug compressed into a hard small disc; some are readily broken along a scored line; others are enteric coated to prevent them from dissolving in the stomach
Tincture- an alcoholic or water-and-alcohol solution prepared from drugs derived from plants
Transdermal patch- a semipermeable membrane shaped in the form of a disc or patch that contains a drug to be absorbed through the skin over a long period of time
Drugs may have natural (plant, mineral, and animal) sources, or they may be synthesized in the laboratory Digitalis and opium are plant derived
Iron and sodium chloride are minerals
Insulin and vaccines have animal or human sources Drugs vary in strength and activity
Official drugs are those designated by the federal Food, Drug, and Cosmetic Act
United States Pharmacopeia (USP) describe drugs according to their source, physical and chemical properties, tests for purity and identity, method of storage, assay, category, and normal dosages
The natural form varies in strength and is difficult to regulate
Pharmacopeia- is a book containing a list of products used in medicine, with descriptions of the product, chemical tests for determining identity and purity, and formulas and prescriptions
The United States’ National Formulary lists drugs and their therapeutic value and can include drugs that may still be used but not listed in the USP.
Pharmacopoeias and formularies are invaluable reference sources for nurses and nursing students Legal Aspects of Drug Administration
Nurses need to know how nursing practice acts in their areas define and limit their functions and be able to recognize the limits of their own knowledge and skill
A nurse who administers the written incorrect dosage is responsible for the error as sell as the physician
The information required (for special inventory forms) usually includes the name of the client, the date and time of administration, the name of the drug, the dosage, an d the signature of the person who prepared and gave the drug
Some agencies may require a verifying signature of another registered nurse for administration of a controlled substance
Food, Drug, and Cosmetic Act- implemented by Food and Drug Administration (FDA); requires that labels be accurate and that all drugs be tested for harmful effects
Effects of Drugs (table 35-4 and table 35-5 pg. 833)
Therapeutic effects (desired effect)- the primary effect intended, that is, the reason the drug is prescribed Side effect- secondary effect, of a drug is one that is unintended; usually predictable and may be either harmless
or potentially harmful; some are tolerated for the drug’s therapeutic effects
Adverse effects- more severe side effects; reactions, may justify the discontinuation of a drug
Drug toxicity- (deleterious effects of a drug on an organism or tissue) results from overdosage, ingestion of a drug intended for external use, and buildup of the drug in the blood because of impaired metabolism or excretion (cumulative effect)
Drug allergy- an immunologic reaction to a drug
Allergic reactions can be either mild or severe. A mild reaction has a variety of symptoms, form skin rashes to diarrhea
Anaphylactic reaction- a severe allergic reaction usually occurs immediately after the administration of the drug; the response can be fatal if the symptoms are not noticed immediately and treatment is not obtained promptly; early symptoms are a subjective feeling of swelling in the mouth and tongue, acute shortness of breath, acute hypotension, and tachycardia
Drug tolerance- exists in a person who has unusually low physiologic response to a drug and who requires increase in the dosage to maintain a given therapeutic effect; drugs that commonly produce tolerance are opiates, barbiturates, ethyl alcohol, and tobacco
Cumulative effect- is the increasing response to repeated doses of a drug that occurs when the rate of administration exceeds the rate of metabolism or excretion
Idiosyncratic effects- one that is unexpected and may be individual to a client; underresponse and overresponse; drug may have a completely different effect from the normal one or cause unpredictable and unexplainable symptoms in a particular client
Drug interaction- occurs when the administration of one drug before, at the same time as, or after another drug alters the effect of one or both drugs; may be beneficial or harmful
o Potentiating effect- effect of one or both drugs may increase; may be additive or synergistic Additive- when two of the same types of drugs increase the action of each other Synergistic- when two different drugs increase the action of one or another drug o Inhibiting effect- effect of one or both drugs may decrease
Iatrogenic disease- (disease caused unintentionally by medical therapy) can be due to drug therapy; ex: hepatic toxicity resulting in biliary obstruction, renal damage, and malformations of the fetus as a result of specific drugs taken during pregnancy are examples
Drug misuse- the improper use of common medications in ways that lead to acute and chronic toxicity Drug abuse- inappropriate intake of a substance, either continually or periodically; drug use is abusive when
o drug dependence- a person’s reliance on or need to take a drug substance; the two types of dependence, physiologic and psychologic, may occur separately or together; a dependent person who stops using the drug experiences withdrawal symptoms
physiologic dependence- due to biochemical changes in body tissues, especially the nervous system; these tissues come to require the substance for normal functioning
psychologic dependence- emotional reliance on a drug to maintain a sense of well-being accompanied by feelings of need or cravings for that drug; varying degrees ranging from mild desire to craving and
compulsive use of the drug
o drug habituation- denotes a mild form of psychologic dependence; the individual develops the habit of taking the substance and feels better after taking it; habituated individual tends to continue that habit even though it may be injurious to health
illicit drugs (street drugs)- those sold illegally; two types: drugs unavailable for purchase and drugs normally available with a prescription that are being obtained through illegal channels; are often taken because of their mood-altering effect (happy or relaxed)
Actions of Drugs on the Body
Actions can be described in terms of its half-life, the time intervals required for the body’s elimination processes to reduce the concentration of the drug in the body by one-half
Because the purpose of most drug therapy is to maintain a constant drug level in the Onset of action- the time after administration when the body initially responds to the drug
Peak plasma level- the highest plasma level achieved by a single dose when the elimination rate of a drug equals the absorption rate
Drug half-half life (elimination half-life)- the time required for the elimination process to reduce the concentration of the drug to one-half what it was at initial administration
Plateau- a maintained concentration of a drug in the plasma during a series of scheduled doses Pharmacodynamics
Pharmacodynamics- the process by which a drug changes the body (alters cell physiology) Receptor- usually a protein, is located on eh surface of a cell membrane or within the cell
Cell membranes contains receptors for physiologic or endogenous substances such as hormones and neurotransmitters
Most drugs exert their effects by chemically binding with receptors at the cellular level
Agonist- a drug that produces the same type of response as the physiologic or endogenous substance
Antagonist- a drug that inhibits cell function by occupying receptor sites; prevents natural body substances or other drugs from activating the functions of the cell by occupying the receptor sites
Pharmacokinetics- the study of the absorption, distribution, biotransformation, and excretion of drugs
Absorption- the process by which a drug passes into the bloodstream; the first step in the movement of the drug through the body
o first-pass effect- when oral drugs first pass through the liver and are partially metabolized prior to reaching the target organ; requires higher oral doses in order to achieve the appropriate effect
o intravenous route is the route of choice for rapid action
o intramuscular route is the next most rabid route due to the highly vascular nature for muscle tissue o subcutaneous route is the slower because it has a poor blood supply
o the rate of absorption of a drug can be accelerated by the application of heat, which increases blood flow to the area; conversely, absorption can be slowed by the application of cold
o some drugs intended to be absorbed slowly are suspended in a low-solubility medium, such as oil
o this route is normally used when other routes are unavailable or when the intended action is localized to the rectum or sigmoid colon
Distribution- the transportation of a drug from its site of absorption to its site of action
o When a drug enters the bold stream, it is carried to the most vascular organs (liver, kidneys, and brain) o Body areas with lower blood supply (skin and muscle) receive that drug later
o Fat-soluble drugs will accumulate in fatty tissue, whereas other drugs may bind with plasma proteins Biotransformation (detoxification or metabolism)- is a process by which a drug is converted to a less active
form; makes place in the liver, where many drug-metabolizing enzymes in the cells detoxify the drugs (product is called metabolites)
Two types of metabolites: active- has a pharmacologic action itself; inactive- does not have pharmacologic action Excretion- the process by which metabolites and drugs are eliminated from the body
o Most metabolites are eliminated by the kidneys in the urine; however, some are excreted in the feces, the breath, perspiration, saliva, and breast milk
o The efficiency with which the kidneys excrete drugs and metabolites diminishes with age. Older people may require smaller doses of a drug because the drug and its metabolites may accumulate in the body
Developmental Factors Affecting Medication Actions
Drugs taken during pregnancy pose a risk throughout the pregnancy, but pose the highest risk during the 1st
trimester, due to the formation of vital organs and functions of the fetus during this time.
Changes to response of meds include: decreased liver and kidney function (result in the accumulation of drugs in the body)
Older people may be on multiple drugs and incompatibilities may occur
Older adults often experience decreased gastric motility and decreased gastric acid production and blood flow, which can impair drug absorption.
Increased adipose tissue and decreased total body fluid proportionate to the body mass can increase the possibility of drug toxicity
Older adults may also experience a decreased number of protein-binding sites and changes in the blood-brain barrier, allowing fat-soluble drugs to move readily to the brain causing dizziness and confusion (esp. when taking beta blockers)
Gender Factors Affecting Medication Actions
Differences in the way men and women respond to drugs are chiefly related to the distribution of body fat and fluid and hormonal differences.
Cultural, Ethnic, and Genetic Factors Affecting Medication Actions
Pharmacogenetics- a client’s response to a drug is influenced by genetic variations such as gender, size, and body composition (vary by race or ethnic group)
Some clients may have slow liver metabolism and not achieve an adequate response to a medication, whereas others are rapid metabolizers and may require lower doses of a medication to avoid adverse reactions
Ethnopharmacology- the study of the effect of ethnicity on responses to prescribed medication; incorporates pharmacogenetics which is the study of the genetic ability to produce enzymes that affect drug metabolism Diet Factors Affecting Medication Actions
Vitamin K found in green leafy vegetables can counteract the effect of an anticoagulant such as warfarin Environmental Factors Affecting Medication Actions
Environmental temperature may affect drug activity.
When environmental temperature is high the peripheral blood vessels dilate, thus intensifying the action of vasodilators.
A client who takes a sedative or analgesic in a busy, noisy environment may not benefit as fully as if the environment were quiet and peaceful
Psychologic Factors Affecting Medication Actions
A client’s expectations about what a drug can do can affect the response to the medication Illness and Disease Affecting Medication Actions
Illness and disease can also affect the action of drugs
Drug action is altered in clients with circulatory, liver, or kidney dysfunction Time of Administration Affecting Medication Actions
Orally administered medications are absorbed more quickly if the stomach is empty. Thus oral medications taken 2 hours before meals act faster than those taken those taken after meals.
Routes of Administration
Oral administration- most common route, least expensive, and most convenient route for most clients; drug is swallowed
o major disadvantages are possibly unpleasant taste of the drugs, irritation of the gastric mucosa, irregular absorption from the gastrointestinal tract, slow absorption, and, in some cases harm to the client’s teeth sublingual administration- drug is placed under the tongue where it dissolves; in a relatively short time, the drug
is largely absorbed into the blood vessels on the underside of the tongue; should not be swallowed (ex: nitroglycerin)
buccal administration- “pertaining to the cheek”, a medication is held in the mouth against the mucous
membranes of the cheek until the drug dissolves; drug may act locally on the mucous membrane of the mouth or systemically when it is swallowed in the saliva
parenteral administration- defined as other than through the alimentary or respiratory tract, by needle; common types: subcutaneous (hypodermic), intramuscular, intradermal, and intravenous
o less common types: intra-atrial (artery), intracardiac (heart muscle), intraosseous (bone), intrathecal or intraspinal (spinal canal), epidural (epidural space), and intra-articular (joint)
topical administration- those applied to a circumscribed surface area of the body; types: o dermatologic preparations- applied to the skin
o instillations and irrigations- applied into body cavities or orifices, such as the urinary bladder, eyes, ears, nose, rectum, or vagina
o inhalations- administered into the respiratory tract by a nebulizer or positive pressure breathing apparatus; air, oxygen, and vapor are generally used to carry the drug into the lungs
Types of Medication Orders
Stat order- indicates that the medication is to be given immediately and only once Single order (one-time order)- for medication to be given once at a specified time
Standing order- may or may not have a termination date; may be carried out indefinitely until an order is written to cancel it, or it may be carried out for a specified number of days; in some agencies, standing orders are
automatically canceled after a specified number of days and must be reordered
PRN order (as needed)- permits the nurse to give a medication when, in the nurse’s judgment, the client requires it; the nurse must use good judgment about when the medication is needed and when it can be safely administered Essential Parts of a Drug Order (PRACTICE WRITING PRESCRIPTION pg. 842)
Client’s full name
Date and time the order is written Name of the drug to be administer Dosage of the drug
Frequency of administration Route of administration
signature of the person writing the order (an unsigned has no validity) boxes 35-1 and box 35-2 pg. 841
Communicating a Medication Order
MAR’s (medication administration records) vary in form, but all include the client’s name, room, and bed number; drug name and dose; and times and method of administration
The nurse should always question the primary care provider about any order that is ambiguous, unusual, or contraindicated by the client’s condition
If the primary provider cannot be reached, document all attempts to contact the primary care provider and the reason for withholding the meds.
Systems of Measurement and Calculations (REVIEW pgs. 844-845) Administering Medications Safely (look at practice guidelines pg. 846)
The medication history includes information about the drugs the client is taking currently or has taken recently An important part of the history is clients’ knowledge of their drug allergies
An illness occurring after a drug was taken may not be identified as an allergy, but the client may associate the drug with an illness or unusual reaction
Also included in the history are the client’s normal eating habits
It is also important for the nurse to identify any problems the client may have in self-administering a medication Then nurse needs to consider socioeconomic factor for all client, but especially for elders. Two common problems
are lack of transportation to obtain medications and inadequate finances to purchase medications Medication Reconciliation
Medication reconciliation- the process of creating the most accurate list possible of all medications a patient is taking-including drug name, dosage, frequency, and route- and comparing drug that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital
the nurse needs to make a complete list of the client’s medication (including prescriptions, vitamins, supplements, and over-the-counter) on admission
Medication Dispensing Systems Medication cart
Automated dispensing cabinet (ADC) Process of Administering Medication (see box 35-3 pg. 850)
1. identify the client 2. inform the client 3. administer the drug
4. provide adjunctive intervention as indicated 5. record the drug administered
6. evaluate the client’s response to the drug
Ten “Rights” of medication Administration (pg. 850 box 35-4) o right medication
o right dose o right time o right route o right client
o right client education o right documentation o right to refuse
o right assessment o right evaluation see box 35-35 pg. 851
Oral Medications (skill 35-1 pgs. 852-855)
as long as the client can swallow and retain the drug in the stomach, this is the route of choice
when clients are vomiting, has gastric or intestinal suction, or is unconscious and unable to swallow they are NPO (nothing by mouth)
See lifespan considerations pgs. 855-856 and home care consideration pg. 856 Nasogastric and Gastrostomy Medication
Nasogastric and gastrostomy tubes- for clients who are NPO; an alternative route for administering medications is through the NG or gastrostomy tube.
Given ID, sub-q, IM, or IV Equipment
o Syringes have three parts: tip (connects with the needle), barrel (outside, where scales are printed), and the plunger (fits inside barrel)
the nurse must avoid letting any unsterile object tough the tip or inside of the barrel, the shaft of the plunger, or the shaft or tip of the needle
insulin syringe- similar to hypodermic but the scale is specifically designed for insulin; calibrated in 100-units
tuberculin syringe- originally designed to administer tuberculin solution, calibrated in tenths and hundredths of a mL
syringes are made in other sizes like: 10, 20, and 50 mL
o Needles- three parts: hub (fits on syringe), cannula or shaft (attached to the hub), and bevel (slanted part of the tip of the needle)
Three variable characteristics:
Slant or length of the bevel: longer bevels provide the sharpest needles & less discomfort
Length of the shaft: common length varies from ½ to 2 inches; length is chosen according to the client’s muscle development, the client’s weight, and the type of injection
Gauge- diameter of the shaft; varies from #18 to #28; larger the gauge the smaller the diameter o Preventing needle sticks (pg. 860 box 35-6)
Preparing injectable medications
o Ampule- glass container usually designed to hold a single dose of a drug; vary in sizes from 1 to 10 mL or more
o Vial- small glass bottle with a sealed rubber cap; come in different sizes, form single to multidose vials; several vials are dispensed as powders in vials and a liquid must be added before it can be injected (reconstitution)
o See skills 35-2 and 35-3 pgs. 862-864 o See skill 35-4 pgs. 865-866
Intradermal Injections- administration of a drug into the dermal layer of the skin just beneath the epidermis; used for allergy testing and TB screening; common sights: inner lower arm, upper chest, and the back beneath the scapulae (left arm for TB and right for all other) skill 35-5 pg. 867
Subcutaneous Injections- just beneath the skin; vaccines, insulin, and heparin; common sites: outer aspect of the upper arms and anterior aspect of the thighs (both have good circulation), abdomen, scapular areas of upper back, and upper ventrogluteal and dorsogluteal areas
o Only small doses 0.5 to 1 mL
o Needle sizes and lengths are selected based on the client’s body mass, intended angle of insertion, and the planned site; generally #25 gauge and 5/8 inch for 45-degree angle and 3/8 inch for 90 degree angle o Pinch skin and determine length of needle (needle length is half the width of the skinfold)
o 45 angle for 1 inch of skin pinched and 90 angle for 2 inches of skin pinched
o Injection sites need to be rotated to minimize tissue damage, aid absorption, and avoid discomfort o See skill 35-6 pgs. 870-872
Intramuscular injections- absorbed more quickly than sub-q injections because of the greater blood supply to the body muscles
o Adult with well developed muscles can tolerate 3 mL of meds in the dorsogluteal and 1-2 mL with less developed muscles
o Deltoid- 0.5-1 mL
o Standard needle is 1½ inches and #21 or #22 gauge
o Indicates the size and length of the needle: the muscle, type of solution, amount of adipose tissue covering the muscle, and the age of the client
o Viscous solutions require a larger gauge (#20 gauge)
o Obese pts. Require longer needle (2 in) and thin pts. need a shorter needle (1 in)
o Contraindications for using a specific site include tissue injury and the presence of nodules, lumps, abscesses, tenderness, or other pathology
o Ventrogluteal site- preferred site b/c: contains no large nerves or blood vessels, provides the greatest thickness of gluteal muscle, is sealed off by bone, and contains consistently less fat the buttock area; place in side-lying, back, or prone positions.
o Dorsogluteal site- don’t give in children under 3 unless the child has been waking for at least 1 yr; make sure you don’t hit the sciatic nerve
o Deltoid site- don’t administer more than 1 mL, recommended for administration of the hep B vaccine in adult o Rectus femoris site- used occasionally for IM injections
Chapter 37 (old book) Three phases of surgery:
Perioperative period- three phases together; the delivery of nursing care through the framework of the nursing process; includes collaborating with members of the health care team, making nursing referrals, and delegating and supervising
Preoperative phase- begins when the decision to have surgery is made and ends when the client is transferred to the operating table
Nursing activities include: include assessing the client, identifying potential or actual health problems, planning specific care based on the individual’s needs, and providing preoperative teaching of the client the family, and significant others
Intraoperative phase- begins when the client is transferred to the operating table and ends when the client is admitted to the postanesthesia unit (PACU), or recovery room.
Create and maintain a safe therapeutic environment for the client and the health care professional
Client’s safety, maintaining an aseptic environment, ensuring proper functioning of equipment, and providing the surgical team with the instruments and supplies needed during the procedure
Postoperative phase- begins with the admission of the client to the postanesthesia area and ends when healing is complete
Assessing the client’s response to surgery, performing interventions to facilitate healing and prevent complications, teaching and providing support people, and planning for home care
Outpatient procedures do not require an overnight hospital stay. Surgical procedures are commonly grouped according to:
o Diagnostic- confirms or establishes a diagnosis; for example, biopsy of a mass in a breast
o Palliative- relieves or reduces pain or symptoms of a disease, it does not cure; for example resection of nerve roots
o Ablative- removes a diseased body part; for example, removal of the gallbladder (cholecystectomy) o Constructive- restores function or appearance that has been lost or reduced; for example, breast implant o Transplant- replaces malfunctioning structures; for examples kidney implant
Degree of urgency- classified by its urgency and necessity to preserve the client’s life, body part, or body function
o Emergency surgery- performed immediately to preserve function or the life of the client (repair a hemorrhage or repair a fracture
o Elective surgery- performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening or to improve the client’s life
Degree of risk- is affective by the client’s age, general health, nutritional status, use of medications, and mental status
o Age- neonates, infants, and older adults are at greater risks than children and adults
the blood volume in an infant is small, and fluid reserves are limited which increases the risk of volume depletion during surgery resulting in inadequate oxygenation of body tissues; because of an infant’s relatively large body surface area and immature temperature regulatory mechanisms, the risk of hypothermia during surgery is significant
because of a lower percentage of body water, decreased kidney function, and a decreased thirst response, elders are at greater risk for fluid and electrolyte imbalances; the older adult may be poorly nourished which can impair healing
o Nutritional status- adequate nutrition is required for normal tissue repair; obesity contributes to postoperative complications such as pneumonia, wound infections, and wound separation; a malnourished client is at risk for delayed wound healing, wound infection, and fluid and electrolyte alterations
o Medications- anticoagulants (increase blood coagulation time), tranquilizers (may interact with anesthetics, increasing the risk of respiratory infections), corticosteroids (may inference with wound healing and increase the risk of infection). Diuretics (may affect fluid and electrolyte balance
o Major surgery- involves a high degree of risk, for a variety of reasons; it may be complicated or prolonged, large losses of blood may occur, vital organs may be involved, or postoperative complications may be likely (organ transplant, open heart surgery)
o Minor surgery- normally involves little risk, produces few complications, and is often performed in an outpatient surgery (breast biopsy, knee surgery, removal of tonsils)
Preoperative consent- prior to any surgical procedure, informed consent is required from the client or legal guardian. Informed consent implies that the client has been informed and involved in decisions affecting his or her health. The surgeon is responsible for obtaining the informed consent by providing the information, and the nurse may witness the signature. If the nurse assesses that the client does not understand the procedure to be performed, the surgeon is contracted and requested to speak with the client before surgery can proceed
The surgical consent form, provided by the agency, protects the client from incorrect/unwanted procedures and the surgeon and agency from litigation related to unauthorized surgeries or uniformed clients.
Preoperative assessment data (box 37-3) (table 37-2)*****(Box 37-4) Preoperative teaching
Information, including what will happen to the client, when, and what the client will experience, such as expected sensations and discomfort
Psychosocial support to reduce anxiety
The roles of the client and support people in preoperative preparation, the surgical procedure, and during the postoperative phase
Skills training Physical preparation
Adequate hydration and nutrition promote healing;; identify malnutrition and fluid imbalance
Enemas before surgery are no longer routine, but cleansing enemas may be ordered if bowel surgery is planned Bath the night and morning before surgery
Remove hair pins and clips should be removed prior to surgery
All jewelry should be removed including body piercing because of risk of injury from burns if an electrosurgical unit is used
Wedding ring should be taped in place by the nurse if they wish not to remove it.
All prostheses should be removes including artificial body parts, such as partial or complete dentures, contact lenses, artificial eyes, and artificial limbs, eyeglasses, wigs, and false eyelashes, and hearing aids
Safety protocols- involves 3 steps
Step 1- preoperative verification at the time of surgery is scheduled, during admission, and whenever the client is transferred to another caregiver
Step 2- marking of the operative site in an unambiguous manner; an “X” is considered ambiguous and cannot be used to mark the site
Step 3- “time-out” final verification of the correct client, procedure, and site
General anesthesia- the loss of all sensation and consciousness; blocks awareness centers in the brain so that amnesia (loss of memory), analgesia (insensibility to pain), hypnosis (artificial sleep), and relaxation (rendering a part of the body less tense) occur
Regional anesthesia- temporary interruption of the transmission of nerve impulses to and from a specific area or region of the body; the client loses sensation in an area of the body but remains conscious.
Topical (surface) anesthesia- applied directly to the skin and mucous membranes, open skin surface wounds, and burns (Lidocaine, Xylocaine, and benzocaine)
Local anesthesia- infiltration; is injected into a specific area and is used for minor surgical procedures such as suturing a small wound or performing
Nerve block- technique in which the anesthetic agent is injected into and around a nerve or small area of body Intravenous block (Bier block)- used most often for procedures involving the arm, wrist, and hand
Spinal anesthesia (subarachnoid block SAB) - requires a lumbar puncture through one of the interspaces between lumbar disc 2 (L2) and the sacrum (S1). An anesthetic agent is injected into the subarachnoid space surrounding the spinal cord
Epidural (peridural) anesthesia- an injection of an anesthetic agent into the epidural space, the area inside the spinal column but outside the dura mater
Conscious sedation- refers to minimal depression of the level of consciousness in which the client retains the ability to maintain a patent airway and respond approximately to commands
Circulatory nurse- coordinates activities and manages client care by continually assessing client safety, aseptic practice, and the environment
Scrub person- usually a UAP but can be a RN or LPN; their role is to assist the surgeon; they drape the client with sterile drapes and handle sterile instruments and supplies
Surgical skin preparations
Clean the surgical site and surrounding area Assess the surgical site before skin preparation
Remove hair from the surgical site only when necessary or according to the primary care provider’s orders or institutional policies and procedures
Prepare the surgical site and surrounding area with antimicrobial agent when indicated Document surgical skin preparation in the client’s record
Review (Box 37-5)
In some agencies, assessments are made every 15 minutes until vital signs stabilize, every hour for the next 4 hours for the next 2 days
Level of consciousness Vital signs
Skin color and temperature Dressing and bedclothes
Drains and tubes
Fluid balance Review (Table 37-3) Potential Postoperative Problems
Deep breathing exercises help exercises help remove mucus, which can form and remain in the lungs due to the effects of general anesthetic and analgesics
Acelectasis- collapse of the alveoli
Encourage the client to do leg exercises taught in the preoperation period every 1 to 2 hours during waking hours Muscle contractions compress the veins, preventing the stasis of blood in the veins, a cause of thrombus (stationary
cloth adhered to the wall of a vessel) formation and subsequent thrombophlebitis (inflammation of a vein followed by formation of a blood clot) and emboli (a blood clot that has moved) Contractions also promote arterial blood flow Encourage the client to turn from side to side at least every 2 hours; turning alternates which lung can achieve
maximum expansion because it is uppermost
Anesthetic agents temporarily depress urinary bladder tone, which usually returns within 6 to 8 hours after surgery When dressing are changed, the nurse assesses the wound for appearance , size, drainage, swelling, pain, and the
status of drains and tubes
The nurse can expect the sequential signs of healing
Absence of bleeding and the appearance of a clot binding the wound edges Inflammation (redness and swelling) at the wound edges 1 to 3 days Reduction in inflammation when the clot diminishes
Diminished scar size over a period of months or years
Penrose drains, or surgical drains are inserted to permit the drainage of excessive serosanguineous fluid and purulent material and to promote healing of underlying tissues
Closed-wound drainage system- consists of a drain connected to either an electric suction or a portable drainage suction such as a Hemovac or Jackson – Pratt; reduces the possible entry of microorganisms into the wound through the drain
Suture- thread used to sew body tissues together; usually removed within 7 to 10 days after surgery Review types and removal of sutures (pgs 972-974)
Review all skills for chapter 37
Chapter 15-Assessing Clients with Integumentary Disorders
The skin, hair and the nails make up the integumentary system. It is the largest organ in the body and provides an external covering for the body, separating and protecting the body’s organs and tissues form the external environment. Disorders of the integumentary structures may be caused by a variety of factors, including allergies, infection,
infestation, cancer and genetic influences. Skin is about 15 to 20 square feet
Weighs about 9 pounds
Each square foot contains 15 feet of blood vessels, 4 yards of nerves, 650 sweat glands, 100 oil glands, 1500 sensory receptors, and 3 million cells that are constantly dying and being replaced.
The skin consist of two main parts:
Epidermis- outermost part of the skin, consists of epithelial cells. It consist of five layers. o Stratum basale- deepest layer its consists of melanin and kerotin
o Stratum spinosum- mitosis occurs at this layer
o Stratum granulosum- consists of glycolipid that slows water loss across the epidermis
o Stratum lucidum-is present only in thick areas of skin, it is made up of flattened, dead keratinocytes. o Stratum corneum- top and thickest layer of skin
Dermis- is the second, deeper layer of skin. Made of a flexible connective tissue, this layer is richly supplied with blood cells, nerve fibers, and lymphatic vessels. It also contains hair follicles, sebaceous glands, and sweat glands. It has two layers papillary and recticular.
o Papillary- consists of ridges, capillaries and receptors for pain and touch
o Recticular- contains blood vessels, sweat and sebaceous glands, deep pressure receptors and dense bundles of collagen fibers.
Superficial Fascia- fatty layer
Glands of the skin:
Sebaceous glands – (Oil glands)- which secrete sebum that softens and lubricates the skin and hair, aids in the prevention of water loss and protects the body from infection by killing bacteria.
Sudoriferous glands- (sweat glands)- 2 types appocrine and eccrine. Ceruminous glands– in ear to trap foreign materials
Skin color- is due to the amounts of melanin in the skin Skin color is influenced by emotions and illneses.
Erythema- areddening of the skin, may occur with embarrassment, fever, hypertension, or inflammation Cyanosis- bluish color of the skin, results from poor oxygenation of hemoglobin
Pallor- paleness of skin, may occur with shock, fear, or anger or in anemia and hypoxia.
Jaundice- is a yellow to orange color visible in the skin and mucous membranes; it is most often a result of hepatic disorder
Hair- eyelashes protect the eyes, nose hairs protect foreign particle from entering the respiratory tract, hair on the head protects the scalp form heat loss and sunlight.
Nails- protect fingers and toes Diagnosis (look on page at chart).
Genetic considerations- Ask about integumentary disorders or abnormalities in immediate family members and their gender.
Health Assessment Interview- Ask about onset, characteristics and course, severity, precipitating and relieving factors, and note the timing and circumstances of any associated symptoms.