Term
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Definition
| Excessive internal\external blood loss |
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Term
Hemorrhage
What places an individual @ risk? |
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Definition
| Trauma pt, blood clots that are dislodged, medications, internal suture slipping, procedure itself, stress on wound |
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Term
Hemorrhage
What shall the nurse watch for?
s\S |
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Definition
| Weakness, drop in blood pressure, hypotension, restlessness, anxiety, decreased cap refill, decreased SPO2, thready pulse, RR rapid, bleeding |
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Term
Hemorrhage
What complications could occur? |
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Definition
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Term
Hemorrhage
Nursing Care interventions |
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Definition
| S\S assessment, apply direct pressure, speed up IV fluids, call Dr., maybe go back to surgery, blood transfusion |
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Term
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Definition
| Partial\complete collapse of the aveolli (end of bronchioles) |
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Term
Atelectasis
What places an individual at risk? |
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Definition
| Bronchial obstruction, lack of surfacant, general anesthia, decrease mobility, sedation, (Shallow Breathing) |
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Term
Atelectasis
What shall the nurse be watching for? |
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Definition
| Chest pain, dyspnea, HR+RR+Temp increase, BP Change, jug. Vein distention, O2, crackles and wheezing |
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Term
Atelectasis
What complications could occur? |
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Definition
| Hypoxemia, pneumonia, resp failure that can lead to death |
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Term
Atelectasis
Nursing care to prevent and treat |
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Definition
| Use humid O2, deep breathing exercise, SMI, Early ambulation, lung assess, VITALS |
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Term
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Definition
| Acute inflammation of the lungs (aveoli) caused by MO |
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Term
Pnemonia
What places an individual at risk? |
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Definition
| Age, immobility, diabets, NG, Upper Resp. infection, trach, dehydration, decreased nutrition |
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Term
Pnemonia
What shall the nurse watch for? |
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Definition
| Fever, chills, shortness of breath, perlulent sputum (thick, yellow, green), escessive confusion with elders, crackles, restless, Chest Pain, increased WBC |
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Term
Pnemonia
What complications could occur? |
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Definition
| Sepsis, pleural effusion, pleuresis, endocardinitis |
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Term
Pnemonia
Nursing care to prevent and treat |
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Definition
| Patient teaching, Stop smoking, mobility, hydration, preventative vaccines, antibiotic treatment, lung assessment, Vitals |
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Term
Paralytic Ileus
What is it? |
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Definition
| Lack of intestinal peristalsis and absence of bowel sounds |
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Term
Paralytic Ileus
What places an individual at risk? |
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Definition
| Anesthesia, surgery (ab. surg), hypokalemia, peritinitis, decrease activity, opiods, narcotics |
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Term
Paralytic Ileus
What shall the nurse be looking for? |
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Definition
| Lack of bowel sounds, ab. pain, distension, electrolytes imbalanced, At first high pitch Bowel sounds, no paristalsis, vomiting |
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Term
Paralytic Ileus
What complications could occur? |
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Definition
| Bowel obstruction, impair healing, spetic, dehydration in vascular space, malnutrition |
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Term
Paralytic Ileus
Nursing care to prevent and treat |
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Definition
| NG tube, mobility increase, increase fluid intake, bowel sounds, VS, provide comfort measures, decrease narcotic use |
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Term
Deep Vein Thrombosis
What is it? |
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Definition
| Blood clot, Bronchoflibotis (Clots inflammation in deep vein ex. illiac or femoral) lower extremities |
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Term
Deep Vein Thrombosis
What places an individual at risk? |
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Definition
| People on bedrest, post op, past DVT, hx of DVT, CHF, ORtho. Surg, clotting disorders |
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Term
Deep Vein Thrombosis
What shall the nurse watch for? |
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Definition
| Swelling, pain, tenderness, pain in calf or thigh, redness, heat, cramps |
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Term
Deep Vein Thrombosis
What complications occur? |
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Definition
| Pulmonary embolism, stroke, heart attack, poor venous return\poor circulation |
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Term
Deep Vein Thrombosis
Nursing care to prevent and treat? |
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Definition
Promote leg exercising, SCD's, tethose, Pump your feet, rotate you feet, rotate ankles, lift knee up pull towards body
May order ultrasound
May be on bedrest |
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Term
Urinary Retention
What is it? |
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Definition
| inability to excrete urine even though it's produced (6-8hrs without urine) |
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Term
Urinary Retention
What places an individual at risk? |
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Definition
| Epidural, opiods, anticholinergic, surgery, pain med, decreased mobility, NPO, Surgery on lower abdomen , bladder, urethra, enlarged prostate |
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Term
Urinary Retention
What shall the nurse watch for? |
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Definition
| Edema, distention, abdominal, pain, low output |
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Term
Urinary Retention
What complications could occur? |
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Definition
| Pain invention, UTI, and infection (kidney) |
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Term
Urinary Retention
Nursing Care to prevent and treat |
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Definition
| Monitor I's and O's, in and out cath, ambulate, watch weight, bladder scan, give cholinergic |
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Term
Delayed wound healing\infection
What it is |
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Definition
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Term
Delayed wound healing\infection
What puts pt at risk? |
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Definition
| smokers, obesity, malnutrition, immunosupressed, diabetes, excessive strain, meds |
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Term
Delayed wound healing\infection
What shall the nurse watch for? |
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Definition
| Fever, redness, odor, drainage, heat, maybe hard enderation(?), not approximated\closed |
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Term
Delayed wound healing\infection
What complications could occur? |
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Definition
| Dishensence, evisceration, infection |
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Term
Delayed wound healing\infection
Nursing care to prevent and treat |
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Definition
Low fowlers, cover exposed area (if dishence) evisceration-saline moistened guaze cover
Get VS, and call Dr. Stay with pt. at bed side, start surg. prep, nutrition (protein) |
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Term
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Definition
| Pre op, intra op, post op |
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Term
Pre op
What do you need to know before surgery? |
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Definition
| Is the pt preg, do they have a history of bleeding, do a good head to toe (Cardio, mental status, Resp, circulation) Fears and concerns they have, Give easy to understand teaching, SMI assessment, Pain control |
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Term
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Definition
diuretics-check electrolytes, Meds (Anticoagulants), Antiplatelets (NSAIDS)-increase risk of bleeding
If they take insulin you may have to start an IV with glucose
Drug allergies, assess how they do with hypnotics sedatives |
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Term
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Definition
| Maybe EKG, basic profile (Sodium, potassium, glucose, BUN, creatine), |
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Term
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Definition
| Previous surgeries, DNR?, advance directive, hx of blood clots, do they have altered mobility, a support system, alcohol intake (recreational drugs), Do they smoke (decreased healing), Chronic Illness, Nutritional status, how they respond to anesthetics |
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Term
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Definition
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Term
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Definition
| Dentures out, contacts out, prosthetics removed, polish removed, remove body piercings, In gown, current Vitals, band on, voiding prior, skin prep (look at pg 837) |
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Term
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Definition
Has physician explain procedure (nurse reinforce what he says)
Pt. will understand procedure, given voluntarily, competent to sign |
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Term
Informed consent
Emergency surgery |
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Definition
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Term
| Minor surgery consent (Majo. under 18) |
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Definition
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Term
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Definition
Definitive identification of pt and surgical site
Verify components of checklist
everything is in place and ready to go!
TRANSFER TO OR |
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Term
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Definition
Help pt return to original state or better
Protect the pt
Facilitate coping with change |
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Term
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Definition
| Sedative, surgeon talks, anesthesiologist talks, admin drugs, start iv fluids, verify, correct site |
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Term
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Definition
Monitor safety
Sterile technique, continous monitoring, accurate sponge count\instrument
Breaks for personnel
Time out
Verify pt. and check |
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Term
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Definition
Loss of protective reflexes, depression of cardiac\respiratory function, medications associated with dangerous side affects.
Given-IV or inhalation
Very common but has greatest risk
Watch vitals and assess mental status\RR\Cardiac |
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Term
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Definition
Nerve block (ex. face, head)
Not totally unconscious, watch for return of sensation, may have trouble voiding
Ex) epidural-> post op pain control (ab. surgeries)->watch VS
(LandD)->fentanol-> IV and PRN (not as often a PCA)Anesthesia |
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Term
Topical\Local
Moderate Sedation |
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Definition
Rub on numbing stuff (consious sedation)Used when you need pt. cooperatoin
Usually causes amnesia!
Look at LOC! |
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Term
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Definition
done within 28-48hours
ex) gallbladder, colon resection |
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Term
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Definition
Scheduled in advance
ex) hernia, face lift |
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Term
| Taylor pg. 821 Just look over be familiar with |
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Definition
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Term
| What is the priority assessment for post op? |
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Definition
| Respiratory! (Irregular or too depressed) |
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Term
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Definition
Immediate post op care focuses on on: preventing complications from anesthesia and surgery
Take vitals, check the incision, blood pressure, pain assess, nausea, FandE balance, may bed pan (Coping with foleys, drains, chest tubes) |
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Term
Continous monitoring. Are they ready for discharge? Aldrete Score
Look at link on powerpoint |
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Definition
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Term
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Definition
| 2 pt. identifier, improve communication, reduce hospital caused illness |
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Term
|
Definition
| Wrong pt, wrong site surgery, medication allergy, retained sponge and equipment, potassium mishaps, pressure ulcers, lifting injuries |
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Term
| Most common post op complications |
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Definition
FVD (NG, drains, bleeding) hemorrhage, FVE (Lots of Iv Fluids, ADH and Aldosterone)
Assess for edema, lungs, VS, daily weights |
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