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1224 Cards in this Set
- Front
- Back
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Average male total body water |
42 Litres |
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Vital Organs for homeostasis of fluid levels |
Kidneys, Heart, Lungs (ACE), Adrenal glands, Pituitary glands, parathyroid glands |
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Electrolyte examples |
Na, Mg, K, Phosphate |
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Signs of fluid imbalance |
Arrythmia, BP changes, weight changes, swelling, muscle weakness, cramping, dizziness |
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Hormone secreted and produced by the adrenal cortex involved in fluid retention |
Aldosterone |
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How does the parathyroid glands help maintain electrolyte |
Regulates Ca and Phosphate absorption |
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Where is ADH released? (Anti-Diuretic Hormone) |
Pituitary gland (and made in hypothalamus) |
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How to assess fluid balance |
Measuring urine output, neurovasular obs (due to Na), auscultate lungs, fluid balance chart, electrolytes and renal function (check bloods), vital signs |
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Normal Urine Output |
1500-200ml per day or
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What is specific gravity and what is the normal level? |
Is density/concentration. The kidney's ability to conserve water. |
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What is the significance of high levels of Creatinine in the blood? |
The end product of muscle metabolism. |
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Some things to consider in cardiovascular assessment |
Capillary refill, skin turgor (esp in dehydration), heart rate, BP, orthostatic hypo-tension (esp in dehydration), dizziness, hemoglobin levels |
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Respiratory indicators of fluid imbalance |
Pink frothy sputum (oedema), O2 Sats, Crackle sounds in chest, Shortness of breath, increased work of breathing |
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Examples of fluids |
Ice cream, oral fluids (incl juice), ice chips, jelly, tube feeding, flushes (tube or I.V.), IV meds & fluids |
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Things to put in output section of fluid balance chart |
Urine output (measure in pan or bottle OR if they have an IDC), vomit, diarrhea, wound and tube drainage, bleeding, soaked linen (Hyperhidrosis/ excessive sweating |
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Forms of Fluid Therapy and Routes |
Following fluid requirements/restrictions |
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What is PICC? |
Peripherally inserted central catheters |
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What is CVC? |
Central Venous Catheter |
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Examples of crystalloid fluids |
Hypotonic (<250mOsm/L) 5% Dextrose in H2O |
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Examples of Colloid fluids |
Anything with proteins 40 or 7 Hetastarch
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What is total parenteral nutrition? |
Feeding via a tube |
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Examples of Isotonic Solutions |
Lactated Ringers |
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What to do when a blood transfusion is ordered and how to do it |
1. Contact blood bank 2. Inform blood bank of pt details 3. When told its ready, go to collect it with I.D, pt chart and pillowcase (to hide the blood) 4. Locate and confirm blood paperwork is correct/same as pt chart 5. Locate the pt's blood 6. Reconfirm its the right blood 7. Document in blood bank record book that you are taking the blood 8. TRIPLE CHECK 9. Take blood product paperwork with you and carry blood in the pillow case 10. 30 sec hand wash 11. Check unit with RN or endorsed enrolled nurse 12. Remove and clamp leukocyte filter 13. Piece blood bag with the trocar of the leukocyte filter 14. Open blood giving set and put into leukocyte filter 15. Hold leuko filter high and upside down, unclamp 16. Turn right way up after filter is full. 17. stay with pt at least 15min to watch for reaction |
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How to do neuro assessment/ What is AVPU? |
A : Awake - See if pt is awake P : See if pt responds to pain : Put pressure on superorbital notch (eyebrow area) or squeeze trapezius muscle (Above clavicle) |
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What is the Glascow Coma Scale? |
Score out of 15 for CNS obs. 15 is best score 3 - To speech 2- To pain 1- Nil response Best Verbal response 1-5 (Orientated to no sound) 4- Confused 3 - Random words/Word Salad 2 - Incomprehensible 1 - No sound Best Motor Response 1-6 6 - Obeys instructions 5 - Localises to touch or pain (poking) 4 - Withdrawing to pain (flinching) 3 - Flexing abnormally 2- Extending limbs 1 - No movement to painful stimuli |
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How to test pupil response |
Using a light - light from lateral side of pt toward nose Test for even and reactive pupils Describe as brisk/sluggish or fixed |
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What is PEARL? |
Pupils Equal and Reactive to Light |
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What is it called when both pupils constrict/react evenly? |
Consensual Response |
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What can cause sluggish pupil reaction? Esp post-op? |
Narcotics/Opiods |
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How does light in a room affect pupils? |
Will affect pupil SIZE but NEVER speed of reaction! |
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What drug can cause dilated pupils? |
Atropine |
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Most important things to record regarding CNS eye exam? |
Pupil size, shape and pupillary reaction (including if consensually responding evenly) |
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What are the 12 ECG landmarks/Places to put leads? |
V1: Fourth intercostal space to the right of the sternum RA –Right arm RL –Right Leg LA –Left arm LL –Left leg |
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How do you minimise errors on an ECG? |
- Turn off anything electronic including lights - Place leads flat as possible and un-cross them best you can - Accurate lead placement - Make sure dots are secure/flat - Get pt to stay still |
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How do you calculate heart rate from a rhythm strip? |
If regular, 300 / (number of large squares) between QRS complexes |
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How much are big and little squares in an ECG rhythm strip worth? |
Little - 0.04 sec |
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What is the main purpose of fluids and electrolytes to the body? |
To help maintain homeostasis and systemic perfusion |
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What is ADPIE? (Nursing Process) |
A : Assess |
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Who initiates fluid balance charts (FBC's)? |
The nurse |
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How often do you check fluid output? |
Every 6 hours max unless otherwise specified |
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What do you need to check before getting blood for a pt from the blood bank? |
INFORMED CONSENT!!! Prescribed order (inclu x-match/I.V. Order) Vital signs done |
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Which blood types can have which blood? |
Positive with positive, Negative with negative ALWAYS B with O or B |
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Which blood type can give to anyone and why? |
O- because there are no antigens on it o it does not trigger an immune response in anyone ; super safe <3 |
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When are Irradiated blood products given? |
To prevent transfusion-associated graft-versus host disease |
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What are Leucodepleted blood products? |
Means the leukocytes (WBC) are removed so they don't attack the person receiving the blood |
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What are RBC washed with and why? |
With 0.9% Sodium Chloride to remove the majority of plasma proteins, antibodies and electrolytes.
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What are the indications for giving a blood transfusion? |
For treatment of clinically significant anaemia with symptomatic deficit of oxygen carrying capacity, and for replacement of traumatic or surgical blood loss. |
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How much haemoglobin does each unit of RBCs have? |
Enough haemoglobin to raise the haemoglobin concentration in an average size adult by approximately 10g/L. |
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How long can blood transfusions go for? |
4 hours max unless special circumstance |
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What temperature is blood stored at? |
In a special fridge with an alarm. Blood is stored between 2-6c. |
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We gently 'inverse' blood before giving it to a pt. What is inversion? |
Rotating blood to opposite direction/sides |
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What fluid do we use after giving a blood transfusion to do a flush (to make sure pt got all the blood product)? |
0.9% Sodium Chloride flush after giving a blood product - to also make sure blood doesn't stay in line/clots it. |
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Why can blood/blood components only be warmed in a specific blood warming device? |
Blood must never be warmed in a microwave or bowl of hot water as this can cause haemolysis and liberation of potassium that can be life threatening, and denature protein in the plasma. |
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How warm do we warm blood to and when is it indicated? |
Warmed no higher than 41c |
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How slow should a transfusion be for the first 15min for a healthy adult? |
5mL/min |
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What do you do if a pt has a transfusion reaction? |
a) STOP Transfusion b) Remain with patient !!! <- c) Check for DRSABCD d) Monitor Vital Signs and general appearance of patient and repeat checking procedure including identity of patient’s details, forms and blood product labels e) Maintain IV access by keeping line open with 0.9% sodium chloride- do not flush existing line- use a new IV line or you will push more transfusion fluid into the pt f) Alert senior staff and medical team g) Prepare for possible Cardiorespiratory arrest h) Treat and stabilise patient as per medical orders i) Collect blood specimens and tests as ordered j) Complete Transfusion Reaction Report, send blood product with attached giving set and appropriate specimens to blood bankk) Complete incident report on MPHI VHIMS intranet sitel) Document events in patient medical history |
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What is DIC? |
Disseminated Intravascular Coagulation |
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What is tested in blood after it is donated? What is it screened for? |
Syphilis, hepatitis B and C, HIV and HTLV (Human T-lymphotropic Virus) |
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What are the main blood components and why are they given? |
- Red cells : are used to alleviate signs and symptoms of anaemia due to blood loss, disease or treatment. - Platelets : are used for the prevention and treatment of bleeding in patients (thrombocytopenia) or platelet function defects. - Plasma : contains proteins such as clotting factors and antibodies. The plasma can be stored frozen in bags (e.g. fresh frozen plasma) or separated (fractionated) into different components used for specific indications. |
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What Hb levels may mean someone needs a blood transfusion? |
Hb concentration <70g/L OR <80 g/L if Pt suffers from ACS (Acute Coronary Syndrome) |
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What is a pre deposit autologous donation? |
Donating own cells or tissue to be later used on yourself usually after a procedure/surgery |
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What is TACO? (Not the food!) |
Transfusion Associated Circulatory Overload |
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What is acute normovolaemic haemodilution? |
The removal of 1-3 units of blood when anaesthesia is induced and swapped for a colloid or crystalloid solution to reduce RBC loss during a procedure. The blood is replaced after procedure ends. |
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How can dehydration or overhydration affect Hb readings? |
Dehydration makes Hb seem dense/higher than it really is |
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Non blood transfusion treatments of blood loss/Low Hb levels |
- If haematinic deficiency (iron, B12 or folate) replacement therapy may eliminate the need for transfusion correction of the cause of bleeding (e.g. reversal of anticoagulant effects, surgical intervention) - minimising blood loss due to surgery and blood sampling. There are a number of techniques that can assist with this - erythropoietin stimulating agents may increase the haemoglobin level without the need for transfusion and is used in certain patient groups where the risks outweigh the benefits, such as those with chronic kidney disease |
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What is a reticulocyte? |
A very young RBC |
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What is TRALI? |
Transfusion related acute lung injury |
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What is CMV negative blood? |
Cytomegalovirus (CMV) seronegative blood components minimise the risk of transfusion transmitted CMV infection> - pregnant patients - haematology-oncology patients - immunosuppresed patients such as transplant recipients. |
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Why are blood transfusions usually not done at night and usually done during the day? |
Blood bank still open More staff if things go wrong |
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What info must be on a blood sample tube? |
Pt Surname Pt first name(s) Pt Record number and/or Pt D.O.B Date & Time of collection Collector's initials |
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What is the order of blood taking procedure? |
1.Identify patient 2.Collect sample 3.Label samples with full patient details 4.Add time and date of collection to container label 5.Compare patient details on sample and request form 6.Sign blood samples and request form declaration |
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How long are blood samples valid for when a pt is receiving a transfusion? |
72 hours - Patient is pregnant or has been pregnant within the last 3 months. 7 days - Patient not pregnant or transfused within the last 3 months. 1 month for plasma/serum which has been separated and stored below -20 °C |
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How do you check it is the right blood pack for a transfusion? |
Ensure that the pack details on the blood component label, the attached patient compatibility label and transfusion compatibility report (if used) are identical. This includes the: - blood group of patient and donor - blood donation number - crossmatch expiry and pack expiry date and time. |
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What visual inspections are made to a blood pack immediately prior to a transfusion? |
- That the bag is intact with no evidence of leaks or tampering - There are no clots, unusual discolouration or turbidity (which may indicate bacterial contamination) - There is no significant colour difference between the segments of tubing attached to the bag and the red cell pack. |
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What are the signs of an transfusion reaction? |
- Rash (urticarial/hives) - Wheezing - Dyspnoea - 1 °C+ temp increase - Chills - Rigors - Hypotension (Shock) - Tachycardia - Nausea/Vomiting - Generalised oozing (due to disseminated intravascular coagulation (DIC) developing) - haemoglobinuria (Blood in urine) - Oliguria (Severely low urine output) Patients may also complain of - Chills - Flank or IV site pain - Itching - Nausea. They may report feeling anxious, generally unwell or have an impending sense of doom. |
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What are the acute transfusion reactions? |
Severe febrile (non-haemolytic) transfusion reactions - Allergy and anaphylaxis (including IgA/anti-IgA reactions) - Acute haemolytic transfusion reactions - Transfusion-associated circulatory overload (TACO) - Transfusion-related acute lung injury (TRALI) - Transfusion-transmitted infection (TTI) including sepsis from bacterial contamination of blood components. |
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What do you do if there is a transfusion reaction? |
If a transfusion reaction is suspected you must: - Stop the transfusion - Act (vital signs, maintain IV access w/ 0.9% saline, institute emergency treatment, clerical check) - Notify the medical officer and transfusion service provider. |
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Consciousness Definition |
Person is aware of environment and self and able to respond appropriately to stimuli |
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Altered level of consciousness |
When a pt can't follow commands, isn't orientated or needs persistent stimuli to achieve alertness |
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Causes of altered level of consciousness |
Toxilogical (Drugs/Alcohol) Decrease in glucose and oxygen (Cardiovascular) Diabetes (Insulin) |
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Mnemonic for Altered levels of consciousness |
AEIOU TIPS I - Insulin (Diabetes) T - Trauma, toxins, tumours I - Infection (Sepsis) |
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Proper name for stroke (ischemic) |
Cerebral Vascular Accident (no oxygen to tissue) |
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Define Full consciousness |
Alert, oriented to time place and person, comprehends spoken and written words |
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Define confusion |
Unable to think rapidly and clearly, easily bewildered, poor memory and short attention to span, misinterprets stimuli, judgement is impaired, responds inappropriately |
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Define disorientation |
Not aware or not orientated to time, place or person |
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Drowsy |
Lethargic, somnolent (sleepy/drowsy), responsible to verbal stimuli or tactile stimuli but quickly falls back to sleep |
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Define Stupor |
Generally unresponsive, may be briefly roused by painful/repetitive stimuli or shrink away/grab the stimuli |
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Define semi comatose |
Does not move spontaneously, vigorous or painful stimuli may get them to moan or withdraw |
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Define coma |
Unrousable, may have slight non purposeful movement. Does not respond or moan to stimulus |
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Define deep coma |
Completely unrousable and unresponsive to all stimulus. No brain stem, corneal, pharyngeal, tendon or plantar reflexes. |
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What are Sequential Compression Devices (SCDs) and its purpose? |
Devices designed to limit the development of Deep Vein Thrombosis (DVT) and Peripheral Edema in immobile patients. |
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What are the important values of the GCS |
< 8 = Coma (Usually needs intubation) |
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What is the highest priority in altered LOC patients? |
DR ABC (ALWAYS OMG) |
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What can you maintain a pt airway with? |
Gadelle airway |
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Negative consequences of altered LOC |
Ineffective airway clearance (sputum, fluid buildup etc) Increased risk of injury Inability to take fluids by mouth (dehydration, lower SV) Mouth breathing & Impared mucous membranes Impaired skin integrity due to lack of movement (pressure sores) |
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Define corneal reflex |
Closure of lids on irritation of the cornea |
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What is DVT? |
Deep Vein Thrombosis |
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Define Epilepsy |
Condition characterised by abnormal electrical impulses of the brain leading to seizures |
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Define Hypoxia
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Inadequate oxygen to the cells |
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Define Pharyngeal reflex
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Contraction of the pharyngeal constrictor muscle elicited by touching the back of the pharynx |
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Define seizure |
Temporary alteration in behavior caused y a massive electrical discharge in the brain |
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Define syncope |
Brief loss of consciousness caused by inadequate brain diffusion. (fainting) |
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Define TIA |
Transient Ischemic Attack (ministroke but isn't really a stroke) |
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Define vasovagal response |
Temporary stimulation of the vagus nerve which causes a drop in HR and decreased CO |
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What is not in GCS but should always be part of neurological obs? |
Eye assessment especially pupil size/reaction |
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What is tramadol? |
Narcotic analgesia High rate of oral absorption Tramadol crosses both the placenta and the blood brain barrier |
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What are the indications for tramadol? |
Relief of moderate to severe pain |
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Reasons for giving or not giving an IMI? |
•Faster absorption than SCI •Low risk of infection •Higher risk of nerve or blood vessel damage than SCI •Can inject up to 5 ml (3ml recommended) •Needles size may include 21, 23 or 25 gauge and 1-1.5 inches in length |
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What is an IMI? |
Intramuscular Injection |
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Name the three parts of a syringe |
TIp (Luer slip or luer lock) |
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Name the three parts of a needle |
Bevel (Tip that goes into pt) |
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What gauge needle is best for sub cuts? |
25 |
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What is a SCI? |
Subcutaneous Injection |
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What gauge needle is best for drawing up? |
18 or 19 gauge |
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What gauge needle is best for IMI? |
21 or 23 |
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How do you give an IMI? |
•Use 21 or 23 gauge needles •Inject at 90 degrees •ALWAYS aspirate prior to injection (draw up to see if there is blood - blood means you hit vein and it is no longer an IMI and you need to start again! BOOOOO) •May use z-track method •May use airlock technique |
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Name sites suitable for IMI |
Deltoid (upper outer arm) |
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Name characteristics of this injection site : |
•Easy access
•Close proximity to radial / ulnarnerves and brachial artery •Suitable for volumes up to 3mL •Not recommended for children (Low surface area) •Suitable positioning of client may include sitting, standing, supine, or prone. •Locate site by measuring 2 -3 fingerbreadths below the acromion process on the lateral midline of the arm. |
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Name characteristics of this injection site : Ventrogluteal |
•Away from nerves and blood vessels •Low incidence of complications •Preferred site for adults and children older than 7 months •Useful for volumes 3-5mL |
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Name characteristics of this injection site : Dorsogluteal |
•Useful for volumes up to 5mL
•High risk of injury to sciatic nerve or major blood vessels •Do not use for children younger than 2 years old or emaciated clients •Position client on side, knees flexed •Locate site by palpating the posterior iliac spine where the spine and pelvis meet. Imagine a line from the posterior iliac spine to the greater trochanter. •Administer medication above imaginary line at midpoint. |
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Name characteristics of this injection site : Vastus Lateralis |
•Easily accessible
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Name the characteristics of a Z-Track |
•Z-track is used to prevent backflow of medication into subcutaneous tissue |
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What are the steps in doing ANTT? |
CONSENT IS ALWAYS FIRST Consult pt records to inform self on the wound Perform hand hygiene then sanitize the trolley Gather equipment and waste bag and place on bottom shelf Perform hand hygiene Remove old dressing Change to pair of sterile gloves |
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What is ANTT? |
Antiseptic No-Touch Technique |
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How do you clean an IV Port? |
- If IV port is notexposed and/orgloves arecontaminated: remove obstruction if needed, clean hands& re-glove |
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Define Sterile |
“free from microorganisms” |
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Define Asepsis |
“freedom frominfection or infectious (pathogenic) material”. |
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Define Clean |
“free from dirt, marks orstains” |
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What ae the core components of ANTT? |
1. Key-Part and Key-Site identification and protection 2. Hand hygiene 3. Glove use 4. Aseptic Fields to ensure or promote asepsis 5. Environmental controls 6. Sequencing of procedure events |
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What are key-parts and key-sites? |
A Key-Part is the part of the equipment that must remain aseptic. A Key-Site is the area on the patient/ client such as a wound, or IVinsertion site, that must be protected from micro-organisms. |
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How long is the duration of a normal QRS complex? |
0.08 – 0.12 seconds |
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When does atrial repolarisation occur on an ECG? |
During ventricular depolarization which hides it from showing on an ECG |
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What happens in the heart during what part of a rhythm strip? |
P - Atrial Depolarization (Atria contract) |
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How long should the interval be between R waves on an ECG? |
< than 0.06 sec |
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What is the normal length of the P-R interval |
0.12 to 0.20 sec
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What are the 3 types of heart rate? |
- Bradycardia = rate of <60 bpm - Normal = rate of 60-100 bpm - Tachycardia = rate of >100-160 bpm |
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What is a Atrial Dysrhythmia |
SA node fails to generate an impulse, the atrialtissue or areas in the internodal pathways mayinitiate an impulse.
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What are the 3 types of Atrial Rhythms |
- Atrial Flutter (many ' F waves' instead of P waves - looks like a saw blade) - Atrial Fibrillation ('F waves' but looks like jagged uneven lines) - Supraventricular Tachycardia (Cannot tell P from T waves - looks like ^/\^/\^/\) |
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What are the types of Ventricular Rhythms? |
- Premature Ventricular Complexes(Looks very angular and very irregular but can still see QRS)
- Ventricular Tachycardia (looks like stalagmites) - Torsades de Pointes (Twisting, smooth and pretty - looks more like sound waves) - Ventricular Fibrillation ( Jerky and can't tell which wave is which) - Asystole (Flatline) - Pulseless Electrical Activity (some type of organized rhythmappears on the monitor even though pt is clinically dead) |
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What does 'mane' mean? |
Morning |
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What does 'nocte' mean? |
Night |
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What does 'bd' mean on a med chart? |
twice a day |
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What does 'tds' mean on a med chart? |
Three times a day |
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What does 'qid' mean on a med chart? |
Four times a day |
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What does 'prn' mean on a med chart? |
"pro re nata" or 'as it is required" |
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What does 'stat' mean on a med chart? |
Immediately |
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What does 'NG' route mean on a med chart? |
Naso-gastric |
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What does 'PEG' route mean on a med chart? |
Percutaneous Enteral Gastrostomy |
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What does 'PR' and 'PV' routes mean on a med chart? |
Per Rectal and Per Vagina |
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How may you write microgram on a med chart? |
Microgram or microg |
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What is PCA? |
Patient Controlled Analgesia |
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What does 6/24 mean but why is it no longer used on med charts? |
Every 6 hours |
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What does 1/7 mean but why is it no longer used on med charts? |
For one day (of the week) |
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What does 1/2 mean but why is it no longer used on med charts? |
Means one half but sometimes mistake for one or two. |
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Do we use trailing zeros after whole numbers on drug charts? Why/Why not? |
We do NOT use trailing zeros after decimal points. |
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Do we use leading zeros before a decimal point? Y/n? |
Yes we use the zero at the start to make it clear that it is a decimal and not a whole number. |
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What is the peritoneum? Describe the two types |
Parietal Peritoneum - Serous layer that lines the walls of the abdominal cavity Visceral Peritoneum - Serous layer that covers the organs in the abdominal cavity |
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What is the peritoneal cavity? |
It is the space between the parietal and visceral peritoneum. It is normally closed in males and there is an opening for the fallopian tubes in females. |
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What is the mesentery? |
a fold of the peritoneum which attaches the stomach, small intestine, pancreas, spleen, and other organs to the posterior wall of the abdomen. |
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Give examples of the intra peritoneal organs |
Stomach, spleen, gall bladder, liver, bile duct, small intestine, large intestine, pancreas and spleen |
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Examples of retro peritoneal organs |
Pancreas, kidneys, ureters and bladder |
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What are Viscera? |
Internal organs |
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How many mL does the gallbladder hold? |
30-50mL |
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Seven F's of abdominal distension : |
Fat Fluid (Ascites) |
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What is a blue tint near the umbilicus also known as? What does it mean? |
Aka Culler's Sign : |
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What can engorged or dilated veins near the umbilicus mean? |
Caput Medusae |
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What can cause irregular patches of tan skin pigmentation? |
Von Recklinghausen Disease |
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What is the valsalva maneuver? |
Reduces the filling of the right and then the left side of the heart . Stroke volume and blood pressure falls, while the heart rate increases. |
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How long does an abdominal quadrant need to lack bowel sounds for before it is deemed that the sounds are absent? |
5min minimum. |
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What is the maximum residual amount that can remain in an enteral tube? |
100mL |
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What are the three types of enteral tubes? |
Nasogastric, naso duodenal and naso jejunal |
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Types of Intestinal tubes |
Miller-Abbott, Cantor, Johnston, Baker |
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Nasogastric Suction tubes |
Levin or Salem sumps |
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Types of abdominal cavity drains |
Jackson-Pratt, Hemovac |
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What is used as a biliary drain? |
T-Tube |
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What are borborygmi? |
Hyperactive but normal bowel sounds |
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What is a PIVC? |
Peripheral Intravenous Catheter |
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What is the definition of a peripheral intravenous device? |
A cannula/catheter inserted into a small peripheral vein for therapeutic purposes such as administration of medications, fluids and/or blood products. |
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What is Phlebitis? |
Inflammation of the walls of a vein. |
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What is DVT and what are the causes? |
Deep Vein Thrombosis |
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What are the nursing responsibilities associated with a patient’s cannula?
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Keep site clean Keep it secure (prevent it ripping out) Keep sterile and clean Look for signs of Infiltration - fluid in surrounding tissue Check for signs of a pressure sore forming Check IV line/Cannula is capped |
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What needs to be included on a label on an infusion |
Date Time |
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What is a general tablet drug formula? |
Strength Required ... Volume of Stock --------------------------- X ----------------------- Stock Strength ......................1 |
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How do you calculate drip rate? (Ignore full stops, won't let me leave spaces in there) |
............................... volume(mL) x drops / mL drip rate (dpm) = ------------------------------------ ..................................... time (h) x 60 |
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How to calculate intravenous infusion volume? |
volume (mL) = rate (mL / h) x time (h) |
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How to calculate rate intravenous infusion rate? (Ignore full stops, won't let me leave spaces in there) |
........... volume (mL) rate = -------------------- ............... time (h) |
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How to calculate intravenous infusion time (duration in hours) |
__________ volume (mL) time (h) = ------------------ ___________ rate (mL/h) |
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What is diplopia? |
Double vision |
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What is an aperient? |
a drug used to relieve constipation |
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What is ROM? |
Range of Movement |
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What is ISBAR? |
Introduction |
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What are the purpose of medical records? |
Facilitates an optimal outcome through accurate, objective and timely descriptions of ongoing care by serving as a method of communication from one health professional group to another and providing an account of relevant patient information.
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What is VTBI? |
Volume to be infused |
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When shouldn't you use oxygen therapy? |
CO2 retainers Individuals with COPD may end up retaining to much CO2 when on O2 Therapy so need close monitoring |
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What is IVAB? |
Intravenous Antibiotics |
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What colour tap is oxygen? |
White |
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What colour tap is room air? |
Black |
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What are the three phases of post operative care? |
Phase I - Immediate post-operative Phase III - No longer requiring assessment |
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What post-operative complications can a pt experience in PACU? |
- Pain - Nausea and vomiting - Haemorrhage - Hypertension - Hypotension - Respiratory Depression - Hypothermia <- BIG ONE |
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How often do you need to check OBs in PACU? |
At least once every 15min |
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Main CVS complications in PACU |
- Hypertension - Hypotension - Shock - Haemorrage - Arrhythmia - Other systemic changes (breathing but less likely) |
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How can you manage a pt's airway? |
- Guedel airway - chin lift - jaw thrust/support - pt positioning (if viable to change) - suction - o2 |
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What are the 5 criteria in the modified Aldrete scale? |
- Circulation (Vitals within 20% of pre-operative levels) - Activity (Mobility) |
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What are some critiques of the Aldrete scale? |
Doesn't account for : - Nausea/Vomiting - Wound ooze or drainage |
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Criteria for discharge to ward includes : |
- Awake and orientated, able to lift head offs pillow and respond to commands - Airway clear, able to cough and maintain with minimal O2 support - OBs stable within 20% of pre-operative levels for 15-30min minimum - Not hypothermia (Temp at least 36) and limited to no shivering - No active bleeding/Surgical complications : dressing dry, intact and doesn't need constant reinforcing - No PONV (Post-operatie nausea and vomiting) - All post-op surgical instructions recieived including when pt can eat/drink/mobilize etc & check for any additional orders |
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What equipment will you need when a pt returns to ward? |
- IV Pole & pump and line - Emesis bowl - Drainage holder - Post-Op forms
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What is included in pre-operative handover? |
- Pt level of communication - Extra needs - Mental status - History & physical exam data |
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What is included in intra-operative handover? |
- Type of Anaesthesia used - Course of surgery - All intra-operative events - Any intra-operative medications - Complications - Loss/Replacement of fluids |
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What is included in post-operative handover? |
- Pt current condition - General care orders - Surgical site care - Meds - Transfusions or fluids needed - Complications to look for |
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Things to check before leaving PACU |
- Pt Condition - When can pt eat/drink (should be documented) - What are the IV orders for fluids (needs to be charted) - Antibiotic orders - Assess the surgical site - Check all drains/Attachments - Surgeon written all specific orders? - Pt positioning (supine? Not to move?) - When can pt mobilize? - Lab tests needed? - Are Full Blood Counts needed? Blood tests? What to look for? - Does pt need anticoagulants ? |
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What should you check when pt returns to wad |
- LOC - Vitals/Obs - Skin colour/temp - Comfort - Pain - FBChart - Dressing - Bedding (may be bloody) - Drains and tubes - N/V - Check urine is being output - Check pt is breathing enough - Give food when allowed (fasting beforehand can be AWFUL) |
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How often are obs done when a pt returns to ward? |
Every 15min for first hour Every 30 for next 2 hours |
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Name some risk factors for nausea and vomiting |
- Non smoker (weird but true) - Female - Long surgery (over 60 min) - Opioid given during/after surgery - History of PONV - History of motion sickness - Opioid - Increased intracranial pressure - Hypoglycaemnia - Dehydration - Given oral liquids too early - Inhaled anesthesia (gas) - Sedation with nitrous oxide (laughing gas) |
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Name risk factors of surgical geriatric pts |
- Higher risk of confusion <- BIG ONE! - Reduced homeostatic efficiency - Confusion may be caused by hypoxia, pain, HTN, hypoglycemia, fluid loss - Ensure adequate hydration |
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Which naso-gastric tube is for decompression? |
Salem Sump |
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Which naso-gastric tube is for feeding? |
Feeding tube (Ryles) |
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What are the potential complications of inserting a NG tube? |
Insertion into the lungs Gagging/Vomiting |
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How do we check that a NG tube has been inserted correctly
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X-Ray |
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How is a paralytic ileus diagnosed?
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Minimal or no bowel sounds |
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Can someone with a naso-gastric tube be orally fed?
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Yes unless otherwise specified |
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What can hyperactive bowel sounds and abdominal distention indicate? |
Mechanical obstruction |
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What are some nursing considerations of someone with a paralytic ileus? |
Naso-gastric suction |
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Why is proper wound care so important? |
- Promote Wound Healing - Complete Wound Healing - Prevent Infection - Prevent Skin Breakdown - Prevent extended hospitalisation - Minimise discomfort experienced by the client - Minimise lifestyle restrictions experienced by the client - Minimise use of excessive resources including the nurses time - Minimise financial burden for the Client and your workplace |
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What are the 3 layers of the skin? |
Epidermis
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What is the skin's pH? |
4.2 to 5.6 (Acidic) |
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Things to consider in a Wound Assessment |
- Type of Wound - Type of Healing - Degree of Tissue Loss - Location - Measurement Dimensions - Exudate - Wound Edges - Surrounding Skin - Pain - Infection - Psychological Impact |
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What is a contused wound? |
A contused wound is where there is an injury to the skin but the skin is intact. |
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What is an abrasion wound? |
Is when there is damage to the epidermis or superficial dermis which is caused by rubbing or scraping which results in an area of the body surface being stripped of skin or mucous membrane. |
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What is an open wound? |
An open wound is one that heals by secondary intention. |
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What is a laceration? |
A wound where the tissues are torn. |
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What is a skin tear? |
A traumatic wound that occurs generally on the extremities of older adults, usually as a result of friction or combined shearing and friction. |
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What is a penetrating injury? |
Injury caused by an object passing through the skin to deeper tissue. |
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What is a fracture? |
A break in the bone |
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What is a perforating wound? |
Where a foreign body passes through body parts. |
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What is a tumour? |
Any malignant or benign growth |
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What are burns? |
Injury caused by thermal, electrical, chemical or radiation source |
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What is primary healing? |
When there is minimal tissue loss and the edges of thewound can be held closed together with sutures, tape or clips and there is minimalscarring |
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What is delayed primary healing? |
When the wound is infected or it contains foreignbodies and requires intensive cleansing prior to closure a few days later |
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What is secondary healing? |
Secondary Healing is when wound healing is delayed and it occurs via granulation, contraction and epithelisation |
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What is a flap in regards to wounds? |
Is the surgical relocation of skin and subcutaneous tissue to the wound from another site |
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What characterizes a stage I pressure sore? |
- Intact skin with non-blanchable redness of a localised area usually over a bony prominence. - Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area. - The area may be painful, firm, soft, warmer or cooler compared to adjacent tissue. - May be difficult to detect in individuals with dark skin tones. - May indicate ―at risk persons (a heralding sign of risk). |
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What characterizes a stage II pressure sore? |
Partial thickness skin loss - Partial thickness loss of dermis presenting as a shallow, open wound with a red-pink wound bed, without slough. - May also present as an intact or open/ruptured serum-filled blister. - Presents as a shiny or dry, shallow ulcer without slough or bruising - should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation |
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Define excoriation |
the act of abrading or wearing off the skin |
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Define maceration |
Softening by the action of a liquid |
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What characterizes a stage III pressure sore? |
Full thickness skin loss
- Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. - Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunnelling. - Bone or tendon is not visible or directly palpable. |
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What characterizes a stage IV pressure sore?
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Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. The depth of a stage IV pressure injury varies by anatomical location. |
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What characterises an unstageable pressure injury? |
Full thickness tissue loss in which the base of the PI is covered by slough Until enough slough/eschar is removed to expose the base of the PI, the true depth, and therefore the stage, cannot be determined. |
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What are the signs of a potential deep pressure injury? |
Purple or maroon localised area or discoloured, intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. |
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What is a superficial wound? |
Involves the epidermis. |
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What is a partial thickness wound? |
Involves the epidermis and the dermis
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What is a full thickness wound? |
Involves the epidermis, dermis, subcutaneous tissue and extends to muscle, bone and tendon |
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Name types of exudate |
Serous (Watery) |
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Signs of skin infection |
- Pain - Heat - Oedema - Erythema - Exudate - Elevated Temperature - Lethargy |
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Define Erythema |
Superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries |
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Define exudate |
a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation. |
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Define transudate |
is extravascular fluid with low protein content |
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Describe wound healing |
Vasoconstriction, platelet response and the biochemical response. |
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What are the phases of tissue repair? |
Inflammation Phase ( 0—3 days ) this is when there is inflammation, haemostasis and the formation of a 'scab‘. |
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What is angiogenesis? |
Growth of new blood vessels from pre-existing ones |
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Things to include when documenting a wound |
- The wound location - The date the wound originated - The original wound type and the intended type of healing - The wound classification (acute / chronic) - Condition of the skin surrounding the wound - Factors which may inhibit healing |
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What are Intrinsic (Internal) things that may affect wound healing? |
o Underlying disease o Diabetes Mellitus o Anaemia o Malignancy o Rheumatoid Arthritis o Autoimmune Disorders o Nutritional Status o Disorders of sensation or movement o Drug Therapy o Radiation o Psychological state o Age |
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What are Extrinsic (External) things that may affect wound healing? |
o Mechanical stress o Debris o Temperature o Drying out o Maceration o Infection o Chemical stress e.g. iodine o Other factors (e.g. smoking, drugs) |
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What is alopecia? |
Hair loss
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What are the eccrine glands? |
The most common major sweat glands and produce a clear, odourless substance, consisting primarily of water and sodium chloride. |
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What is the common name for cerumen? |
Ear wax |
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What is parturition? |
Childbirth |
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What are some age related skin changes? |
- Thinning & flattening of Epidermis may result in the client being more susceptible to skin tears for example - Slower epidermal regeneration may for example extend wound healing time - Dermis atrophies and contracts may result in impaired healing - Elastin fibres reduce in numbers which may reduce the skins ability to heal with the same level of scarring as a young healthy adult - Reduced Langerhan‘s cells and resultant decline in immune competence may impair the clients ability to rebut infection producing pathogens - Decreased blood supply may extend wound healing time - Impaired inflammatory response may extend wound healing time - Reduced numbers of sweat & sebaceous glands - Loss of collagen and subcutaneous adipose tissue may impact on the wound healing and related scar tissue - Altered sensation - Loss of pigmentation in hair - Retarded hair and nail replacement - Increased number of skin lesions - Synthesis of Vitamin D is impaired which may impact on the wound healing process at the stage of inflammation and if bone is involved in the wound9 |
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What are the effects of frequent dressing changes on wound healing. |
- Displacement of wound/Harder to heal - Prevent bacteria sitting in dressing - Prevent wound becoming macerated - Prevent would healing into the dressing (Gauze - only with wrong dressings) |
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What does a jackson-pratt drain look like? |
Similar to a hand grenade |
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What can a hemovac drain be used for? |
Collecting blood to reinfuse into a pt. Is closed |
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In what circumstances would a patient require a PCA and why is it a useful pain management tool? |
- To allow pt control over pain - To allow small, regular doses of analgesia - Allows you to see how often it is requested/needed which can aid nursing assessment - CANNOT GIVE TO PTs THAT ARE NOT COGNITIVELY AWARE |
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What are the potential complications associated with PCA? |
- If no lock out, pt can overdose - Easy to dose on it and pt may become more reliant - Respiratory depression (depends on drug) - Pt may not be able to hit buzzer for it - Sedation - N/V (depending on drug) - CNS disturbance |
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Define respiratory depression |
Hypoventiliation Occurs when ventilation is inadequate (hypo meaning "below") to perform needed gas exchange. |
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List all the possible causes of respiratory depression |
- Head injury/ CNS disturbance - Anaesthesia - Opiate overdose - Bronchiectasis (Bronchi widened) - Pneumoconiosis - Lung carcinoma - Obstruction - Diaphragmatic paralysis - Botulism - PoliomyelitisMetabolic disturbances |
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Describe the different types of surgical wound drains available and how each type works. |
Jackson-Pratt – a soft pliable tube with multiple perforations with a bulb that can recreate low negative pressure vacuum, designed so that body tissues are not sucked into the tube, decreasing risk of bowel perforation. Penrose – flat ribbon-like drain, gauze is applied to external end to absorb drainage, can be colonized by bacteria if left in situ for an extended period of time beause it is OPEN. It is literally just a bit of tubing that gives fluid a slippy slide out of the body. |
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Define Bronchiectasis |
Abnormal widening of the bronchi or their branches, causing a risk of infection |
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Define Pneumoconiosis |
A disease of the lungs due to inhalation of dust, characterized by inflammation, coughing, and fibrosis. |
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Define Botulism |
Food poisoning caused by bacteria |
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Define Abscess |
a swollen area within body tissue, containing an accumulation of pus. |
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When would you use a pigtail drain? |
To remove unwanted fluid from an organ, duct or abscess. |
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Does morphine or fentanyl have a faster onset? When is it better to give Fentanyl? |
Fentanyl has faster onset (3 min lock out) |
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What is naloxone and when is it given? |
Naloxone is an opioid antagonist and is theantidote to morphine. If too much is given,it reverses both respiratory depression andanalgesic effect. Consequently, when patientsare revived they may experience severe pain. It istherefore best to dilute naloxone and administer50mcg doses until respiratory depression isreversed |
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What should you do if a Pt's PCA causes them to have less than 8 RR pm? |
- Call for assistance from the medical team. - - Administer oxygen. - Take the PCA button away from the patientand stop any background infusion. - Sit the patient upright to enable full chestexpansion if suitable - Stimulate the patient. - Continue to monitor the patient, includingrespiratory rate and O2 sats. - Give naloxone as prescribed, following medicaladvice. |
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Define Pruritus |
Severe itching of the skin |
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What is the purpose of controlled huffing? What is huffing? |
Is a controlled form of coughing and starts with pursing the lips and taking amedium to deep breath in. After holding the breath for several seconds, patients exhale byusing the stomach and chest muscles to push the air out fast through an open mouth. • improve ventilation • less tiring than coughing |
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What does PEP stand for? |
Positive Expiratory Pressure |
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What is a bubble PEP? |
- Is a treatment to help patients whohave a build up of phlegm (secretions) in their lungs. - Get the pt to blow out for as long as possible into tubing that is in a glass of water to blow bubbles!!! o O o O o O o Do this 5 times! |
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When taking bloods, what tests would we use the pale green tube for? |
- UE - LFT (Liver Function Test) - Lipids - CA (NOT Ionised CA) - IP - MG - AS ( - CK (Creatine kinase) - CRP (C-reactive protein - inflammation protein) - Drug Levels - Haptoglobin (Cleans free Hb) - Iron Studies - Osmolality - Vit B12 - TFT - Troponin - Plasma Free Haemoglobin. |
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When taking bloods, what tests would we use the gold tube for? |
ASOT, CMV, Cryptococcus, EBV, Hep A, B, C, HIV, Herpes, Rubella, Syphilis, Toxoplasma, Varicella Autoantibodies, Anticardiolipin Antibodies, GAD, IF, B2GP1, ACL, ENA, MPO, PR3 and Gliadins |
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When taking bloods, what tests would we use the pale lilac tube for? |
Essential for— FBE, Hb, DCT, Retics Separate tube for— CD4/8, CD2/3, Cell Surface Markers, Flow Cytometry HbA1c BNP (not NTproBNP), Red Cell Folate Cyclosporin, Everolimus, Sirolimus, Tacrolimus Factor V Leiden, Prothrombin 20210 ACTH, Ammonia, and Homocysteine all on ice. |
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When taking bloods, what tests would we use the pale blue tube for? |
COAG—PT, INR, APTT, Fibrinogen, D-Dimer, Anti-Xa Factor VIII, Factor IX, VWF, RCOF, ATIII, Protein C, Protein S, Lupus Screen. |
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When taking bloods, what tests would we use the red tube for? |
CryoGlobulins, (must be kept at 37C—call lab first) Cytotoxic antibodies, Platelet antibodies |
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When taking bloods, what tests would we use the pink tube for? |
Essential for— Crossmatch G&S G&H Cold Agglutinins (must be kept at 37C—call lab first) |
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When taking bloods, what tests would we use the yellow tube for? |
HLA Tissue Typing— HLAB27, HLA H |
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When taking bloods, what tests would we use the black tube for? |
ESR ONLY |
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When taking bloods, what tests would we use the dark blue tube for? |
Trace & Toxic Metals—Aluminium, Cadmium, Copper,Lead, Mercury, Selenium, Zinc |
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How do you identify where to take blood from a patient? |
- median cubital vein - Depends on pt. Hand and ankle is also done but more painful. |
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What are the advantages and disadvantages of taking blood from the cephalic vein? |
PRO's. •Readily receives a large cannula and is therefore a good site for blood administration. •Splinted by the forearm bones. •Cannula is easily secured. CON's. •Can be more difficult to cannulate than the metacarpel veins. •May be confused with an aberrant radial artery. |
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What are the advantages and disadvantages of taking blood from the basilic vein? |
PRO's •A large vein that is frequently overlooked in the hunt for veins. CON's. •Requires awkward positioning of the limb to gain access to the vein. •The vein tends to roll away when you attempt to cannulate it. •Sites prone to phlebitis. •Cannula port gets caught on sheets |
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What are the advantages and disadvantages of taking blood from the metacarpal veins? |
PRO's
•Easy to see and palpate veins. •Splinted by metacarpal bones. •Allows use of more proximal veins in the same limb should the cannula need to be re-sited. •Cannula is easily accessible in the theatre environment. CON's •Active patients may dislodge easily. •Dressing may be compromised by handwashing. •May be more difficult if the skin is thin and friable. •Flow can be affected by wrist flexion or extension |
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What are the advantages and disadvantages of taking blood from the median veins in the cubital fossa? |
PROs •Large veins and so they will readily accept a large cannula. •Do not "shut down" as quickly as the more peripheral veins. •FIRST CHOICE IN THE EMERGENCY SITUATION. CON's •Can be very positional due to elbow flexion/extension. •Can be very uncomfortable for the patient due to elbow flexion/extension. •Care must be taken not to cannulate the brachial artery. |
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Are there any circumstances where you wouldn’t attempt to take blood from a patient? Explain your answer. |
- Pt is suffering from hypovolemia - There is no rationale for it - Site may be needed for a different procedure/surgery/later cannulation |
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How can you prevent DVTs? |
- Compression (TEDs & Sequential Compression Devices s) - Encouraging mobility if viable - Anticoagulants (Aspirin, Warfarin, Heparin) - In bed exercises if viable - Keeping pt hydrated - Monitoring any surgical sites for haemotoma |
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What does FAST stand for when identifying a stroke? |
F - Facial Drooping A - Arm Weakness S - Speech difficulty T - Time is crucial - Get emergency help ASAP |
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What are some contraindications of anticoagulation therapy? |
- Past history of haemorrhagic stroke - Recent large thromboembolic stroke - Haemorrhagic state - Subacute bacterial endocarditis - Advanced hepatic disease - Pregnancy - Peptic ulcer disease - Severe hypertension (BP>200/120) - Frequent falls - Heparin-Induced Thrombocytopenia - Thrombocytopenia(platelets <70x 10 9 /L) - Cerebral metastatic disease - Bleeding diathesis |
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What are INRs on a blood test? |
International Normalised Ratio |
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What is APTT on a blood test? |
Activated Partial Thromboplastin Time AKA PTT or KCCT Target time is normally 50-75 seconds To help evaluate your risk of excessive bleeding prior to a surgical procedure. To monitor heparin anticoagulant therapy |
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What is FBE on a blood test? |
Full blood examination To see red & white blood cell and platelet count |
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What is U&E on a blood test? |
urea and electrolytes
Electrolytes are usually measured as part of a renal profile which measures the main electrolytes in the body, sodium (Na+), potassium (K+), together with creatinine and/or urea, and may occasionally include chloride (Cl-) and/or bicarbonate (HCO3-) as well. |
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What is LFT on a blood test? |
Liver Function Tests (LFTs) is a group of tests that are performed together to detect, evaluate, and monitor liver disease or damage. |
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What is ALP on a blood test? |
Alkaline phosphatase – an enzyme related to the bile ducts; often increased when they are blocked |
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What is ALT on a blood test? |
Alanine aminotransferase– an enzyme mainly found in the liver; the best test for detecting hepatitis |
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What is Albumin ? |
The main protein made by the liver |
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What is GGT? |
Gamma-glutamyl transferase - an enzyme found mainly in the liver and is a useful marker for detecting bile duct problems |
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Why do we measure creatinine clearance? |
Creatinine clearance rate (CCr or CrCl) is the volume of blood plasma that is cleared of creatinine per unit time and is a useful measure for approximating the GFR (Glomerular filtration rate) |
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What can we monitor LMWH levels when giving people heparin? |
Anti-Xa Assay |
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What are some clinical patterns of a pulmonary embolism? |
- Sudden lung collapse with raised jugular venous pressure - Pulmonary haemorrgage syndrome |
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What is haemoptysis? |
Coughing up of blood |
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What are some risk factors of pulmonary embolism? |
- Recent immobilization - Recent surgery - DVT - Previous PE - Pregnancy or Post-partum - Other major medical illnesses |
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What are ABGs? |
Arterial blood gases |
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What is a V/Q Scan? |
A ventilation/perfusion lung scan |
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What is factor V Leiden thrombophilia? |
The coagulation system is controlled by several proteins, including a protein called activated protein C (APC). APC normally inactivates coagulation factor V, which slows down the clotting process and prevents clots from growing too large. However factor V cannot be inactivated normally by APC. As a result, the clotting process remains active longer than usual, increasing the chance of developing abnormal blood clots. |
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When is it better to use UFH? |
When a person is to undergo surgery such as a coronary angiogram. Bleeding complications can be more likely on LMWH UFH has a shorter half life meaning pt less likely to haemorrage |
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What is HIT(S)? |
Heparin Induced Thrombosis |
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What can we monitor UFH levels when giving people heparin? |
APTT |
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What molecular weight is unfractioned heparin? |
3000 to 30 000 Da |
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What moleculater weight is Low-molecular-weight heparin? |
2000 to 10 000 Da |
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What is the pathogenesis of heparin induced thrombosis (HIT) ? |
Heparin has high affinity for platelet factor 4 (PF4), When heparins and PF4 bind, PF4 undergoes a conformational change, exposing neoepitopes that act as immunogens and lead to the generation of heparin-PF4 antibodies. HIT is caused by the antibodies, most frequently IgG, binding to the heparin-PF4 complex. Heparin-PF4 antibodies in the now-made multimolecular immune complex activate platelets via FcγIIa receptors, causing the release of prothrombotic platelet-derived microparticles, platelet consumption, and thrombocytopenia. = Clot |
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What drugs/substances reverses heparin? (Both types) |
Protamine - (Used to be made from salmon sperm!) Vitamin K (Warfarin blocks the activation of Vit K which is involved in clotting factors I, VII, IX, and X) Fresh frozen plasma (thickens) Prothrombin complex (eg 'Prothrombinex"TM) |
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What are the potential ADRs of Protamine? |
- Acute Hypotension - Shock - Dyspnoea - Anaphylaxis |
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Why give a pt warfarin? |
- Prevent DVTs ('Plastic' valves) |
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What pts are 'risky' to have on warfarin and need close monitoring? |
- 65+ years old - Had changes to drug therapy - Have been fasting - have CCF (Congestive cardiac failure) - Have liver disease - Suffer hypoalbuminaemia (Higher chance of clotting) |
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What are some signs of internal bleeding? (Too much warfarin) |
- External bruising - Abdominal distension and/or pain - Back pain - Hypotension and shock - Collapse - Neurological symptoms - Macroscopic haematuria - Epistaxis - GIT blood loss (haematemesis/malaena) - Headache - Joint, muscle or other pain - Dyspnoea - Stridor - Unexplained fall in haemoglobin |
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What is stridor? |
A harsh, grating sound |
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Define Epistaxis |
Bleeding from the nose |
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Define melaena |
Black, tarry stools Melas translates to black |
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What is Enoxaparin? |
a LMWH
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What blood test is done to monitor someone on a heparin sodium infusion? How often is it done? Why is it so important to do this? |
APTT - Activated Partial Thromboplastin Time It is important to check so the pt can clot and doesn't bleed out internally (rat poison!) and important to make sure the pt isnt in a hypercoagulant state (DVTs/Clots - > PE -> death) |
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Who checks and changes a heparin infusion rate? |
The RN with assistance from another RN or the medical officer |
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Why administer heparin sodium as an IV infusion as opposed to a subcutaneous injection?
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To reach peak plasma levels in the blood it takes 2-4 hours |
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Define Thrombocytopenia |
Deficiency of platelets in the blood. This causes bleeding into the tissues, bruising, and slow blood clotting after injury. |
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What is the common name for a Thrombocyte? |
Platelet |
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What are the 'pros' of LMWH? |
- Less inhibition of platelet function - Lower chance of HIT (Heparin Induced Thrombosis) > Less interaction with factor 4 - Lower chance of thrombocytopenia - Lower incidence of bone loss - Safer in pregnancy - Less lab monitoring - More predictable anti-coag response > Metabolised at a slower rate > Renal clearance > Better bioavailability subcut vs UFH subcut |
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What does DRSABCD stand for? |
D- Danger R - Response |
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What are some Advantages of Parenteral Nutrition (TPN/PPN)? |
- Provides nutrition when GI intolerance prevents oral or enteral access
- Long term option - Can be used in the hospital or at home |
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What is TPN? |
Total Parenteral Nutrition (TPN) |
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What is PPN? |
Peripheral Parenteral Nutrition (PPN) Nutrition is only partially supplied via IV |
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What are the disadvantages of Parenternal nutrition? |
- Catheter infection due to constant IV access - Risk of phlebitis - Costly - Possible long term effects Eg. Liver dysfunction, kidney or bone disease - Increased risk of thrombosis. |
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What is the definition of Parenteral Nutrition? |
IV infusion of nutrition (dextrose, water, fat, proteins, electrolytes, vitamins and trace elements) into a vein, where it is diluted by the pt's blood.
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What are the indications for parenteral nutrition? |
- Severe malnutrition - Severe burns - Bowel disease/disorders - Acute renal failure - Hepatic failure - Metastatic cancer - Major surgeries where nothing may be taken by mouth for more than 5 days. |
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What are the advantages of Enteral nutrition? |
- Less serious complications > phlebitis - More cost and time effective - The use of the GI tract is closer to normal - Preservation of mucosal architecture - Preservation of gut associated lymphoid tissue (GALT) - Preservation of hepatic immune function - Preservation of pulmonary immune function - Reduction of inflammation - Reduction of antigenic leak from gut - Interference with pathogenicity of gut organisms - Less hyperglycemia |
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What are the disadvantages of enteral nutrition? |
-Risk of aspiration -Discomfort of tubing -Risk of tube displacement -Risk of perforation or infection - More invasive - More likely to be uncomfortable for pt |
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What are the indications for a pt to get enteral nutrition? |
- Used when the pt cannot/will not ingest foods orally > includes severe dementia - When the upper GI tract is impaired |
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Definition of enteral feeding |
Nutrition that is delivered directly into the stomach, or small intestine (duodenum or jejunum) |
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Why is Oedema considered cyclic? |
As fluid moves into the tissues, your body attempts to maintain blood/fluid volume as it can tell there is a circulatory deficit. |
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Where is ADH made and where is it stored/released? |
Made in the hypothalamus,stored/released by the pituitary gland. |
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Why you should be cautious when you give Metoclopramide to pt's who have Parkinson's disease, renal failure and depression? |
Metoclopramide is a dopamine receptor antagonist
Dopamine is a natriuretic hormone, increasing sodium excretion by diminishing reabsorption, primarily in the proximal tubule. Natriuetic peptides are increased in pts with kidney failure so causing more natriuresis and fluid loss is not great XD |
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What are the 4 types of pain? |
Nociceptive pain
Neuropathic pain Psychogenic pain Phantom pain |
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Define Nociceptive pain |
- Physiological pain - Arises from stimulation of superficial or deep nociceptors (pain receptor) by noxious stimuli |
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Define Neuropathic pain |
- Arises from a primary lesion in CNS or PNS eg) nerve compression due to collapsed intervertebral disc - Associated with paraesthesia (pins and needles) and allodynia (when you have pain from something that doesn’t usually cause pain, like wearing your shoes or clothing) - Frequently unresponsive to opioids |
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Define psychogenic pain |
- Anxiety, depression and fear cause severe pain- Multimodal approach |
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Define phantom pain |
- Sensations are described as perceptions that an individual experiences relating to a limb or an organ that is not physically part of the body. |
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Define Allodynia |
Pain resulting from a stimulus (as a light touch of the skin) which would not normally provoke pain |
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What is the common name for paraesthesia? |
Pins and needles |
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Define Paraesthesia |
An abnormal sensation, typically tingling or pricking (‘pins and needles’), caused chiefly by pressure on or damage to peripheral nerves. |
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Define fluid shift |
The distribution of the Extra Cellular Fluid is not fixed, so if you lose ECF there will be a change in the osmolality and water will move out of cells to compensate. (Cells will lose water) |
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How does ADH work? |
When ADH is present we get more water channels forming in the distal tubule and collecting duct of the kidney. The hypothalamus sends a message to the pituitary gland which releases ADH. This travels in the blood to your kidneys and affects the tubules so more water is reabsorbed into your blood. As a result you make a smaller volume of more concentrated urine. It makes your nephons more permeable to H2O so less is lost This also makes you thirsty |
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What is another name for ADH? |
Vasopressin |
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How does RAAS work? |
Anytime there is decreased pressure in the renal arteries, reduced sodium levels in the nephon or by the SNS. Kidneys produce renin to activate angiotensin I which the lungs can convert into angiotensin II (converted by ACE) This is a very potent vasoconstrictor and constricts blood vessels and then boosts blood pressure Renins stimulates aldosterone which increases sodium reabsorption in the kidneys. Sodium freely filters through the nephron of the kidneys and in the presence of aldosterone, more sodium is reabsorbed back into the blood, therefore increasing blood volume and blood pressure. |
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How does nitrous oxide work? |
- the action of anaesthetics isn't fully understood
Cl- in (open channel) K+ out (open channel) Ca+ stays out (closed channel) 1) Enhancing the GABA receptor (our inhibitory neurotransmitter) Chloride channels open up and enter the cell, which decreases the charge of the cell and causes CNS depression (Action potential can't occur) 2) Potassium channels (K+) open up and moves OUT of the cell, therefore decreasing the cells charge and causing CNS depression. (Action potential can't occur) 3: Calcium (Ca2+) channels close and can't enter the cell, therefore decreasing the cells charge and causing CNS depression. (Action potential can't occur) |
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Name the three enduring powers of attorney that operate in Victoria |
a. Enduring power of attorney (financial), b. enduring power of guardianship and c. enduring power of attorney (medical treatment) |
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What is the difference between an enduring power of attorney and a general power of attorney? |
General power of attorney stops when the person making the decision can't make decisions! No use if pt is in coma! |
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What holds more power? Someone given powr of attorney or a spouse? |
The power of attorney |
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Define normal sinus rhythm |
Each QRS complex is preceded by a normal P wave with the PR interval remaining constant. |
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Define AF (atrial Fibrillation) |
Rapid misfiring of the sinoatrial node. The P wave is not present with disorganised activity in its place. There are also irregular intervals between the QRS complexes |
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What are some therapies for AF? |
- Anticoagulants: Prevents the formation of clots. > In AF blood pools in the atria and aren't ejected properly -> stasis -> blood clot - Beta blockers: Blocks adrenaline and slows the heart rate. - Calcium blockers: Slows heart rate and reduces blood pressure/Contractility. |
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How can one perform a pain assessment? |
- Can be characterised by asking about intensity, timing, location, quality, aggravating and alleviating factors. (PQRST) - Patient can rate their pain on a scale of 1-10. - Children can be given a visual scale using pictures of faces that exhibit feelings from no discomfort to increasing discomfort. |
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In regards to pain, what is PQRST? |
Provocation/Palliation Radiation/Region Severity/ Timing |
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What are some things to be considered regarding consent? |
- Must be freely given without coercion. - Patient must have a full understanding of the nature and consequences of the procedure. (INFORMED CONSENT) - Persons under 18 years of age cannot give consent for treatment without special circumstance/Proof of independence - Consent must be given in writing - Patients must be made aware that they can withdraw consent at any time. |
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What must be done when a pt refuses consent? |
- Patient must have the capacity to make the decision fully understand what will happen if consent is withdrawn. - The doctor/surgeon would need to be informed as they will most likely wish to discuss it with the patient. - Document the patient’s refusal and reason. |
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What must we consider for documentation to be effective? |
- Must begin with the date and time. - Write legibly. - Mistakes should be crossed out and signed, no white-out. - Must be objective. |
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How would you prepare a pt for theatre? |
- Conduct a preoperative assessment and baseline observations. - Verify fasting status and preoperative preparation (e.g. shaving). - Ensure patient has given written consent and that they fully understand their procedure. - Verify that the surgical site will be in the correct location on the correct side. (It is usually marked) - Ensure the surgical site is easily accessible (No jewellery etc) - Check for allergies and prescribed medications. - Psychological support must also be given and any of the patient’s or family’s concerns should be addressed. |
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What are some post operative nursing responsibilities? |
- Pain levels should be assessed and appropriate pain measures should be administered. - Vital signs and fluid and electrolyte balance should be checked. - Adhere to surgeon instructions. Make sure you have them all! - The nurse should also provide education to the patient about their recovery and assist with discharge planning. |
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What should be checked before getting a pt from PACU? |
- Check that the patient is stable and has a patent airway. - Review essential information to ensure that the patient’s specific needs are met and that obvious complications can be prevented. - Make sure any post surgical orders are received (when can you eat/mobilize) |
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What must be checked in PACU? |
- Assess the patient’s airway, breathing and circulation as well as pain levels. - Administer prescribed medications and fluid or blood component therapies. - Manage complications. - Determine the patient’s readiness for transfer to the ward. |
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Why would temperature rise post operative? |
- Infection - Reaction to a blood transfusion - Inflammation resulting from the surgery - Pain |
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What is atelectasis? |
Collapse of one or more areas of the lungs or the inability to inflate due to respiratory depression caused by anaesthesia |
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Define Pneumonia |
Inflammation of the lung tissue due to infection. |
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What is acute respiratory distress syndrome? |
Accumulation of fluid in the alveoli which prevents oxygen from entering the blood stream. |
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What are some post operative respiratory complications? |
- Atelectasis: - Pneumonia: - Acute Respiratory Distress Syndrome: |
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What is the purpose of the modified aldrete score? |
Allows the nurse to determine whether or not a patient is ready for discharge from the PACU. Allows the nurse to place a numerical score on levels of activity, respiration, circulation, consciousness and oxygen saturation. If the patient has a score of 7-8, they are considered ready for discharge. |
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What does the nurse need to prepare/remember to do when discharging a pt? |
-Educate the patient and their family about home care. - Explain the use of prescribed medications and their adverse reactions. - Make follow up appointments and referrals for any other required health services. - Address any patient concerns. |
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What is a nurses responsibilities in the resuscitation bay? |
- Ensure equipment is ready for use prior to the patient’s arrival. - Maintain a sterile environment by wearing the correct PPE and using sterile procedures. - Assist in assessment and resuscitation. - Administer medications. - Watch for signs of deterioration of the airway, vital signs and level of consciousness. |
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What must a nurse do when performing wound care? |
-Check location, size and depth and presence of pain, inflammation and infection. - Apply dressings and prescribed topical solutions, as well as administer pain relief . - Dressing should be kept dry and the nurse must use the sterile technique when changing them to avoid contaminating the wound. - Educate the patient about their wound care. |
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What must a nurse consider when a pt has a PCA? |
- Ensure that the patient fully understands the operation of their PCA. - Frequently assess sedation score, pain score and respiratory status in case of opioid overdose. - Naloxone is an opioid antagonist which should be used in the event that an overdose occurs. - The date and time that the PCA is ceased must be recorded. |
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What are the four elements of a valid consent? |
- Voluntary - Specific - Informed - Legal capacity |
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What are examples of implied consent? |
Nodding yes Getting a 'thumbs up' sign |
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Consent may be in what 3 forms? |
Written, verbal or implied |
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What is a surgical drain? |
Tube exiting the peri-incisional area into either a portable wound suction device (closed) or into the dressings (open). - Allows escape of blood and serous fluids that allow bacteria growth. - Types of drains include Penrose, Jackson-Pratt and Varivac. |
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What must nurses do when caring for a drain? |
- Record drainage output and the amount of drainage on the dressing itself. - Spots of drainage on the dressings are outlined with a pen and the date and time is written beside it so that increased drainage is easy to identify. - Excessive drainage should be reported to the surgeon. - Dressings can be reinforced with sterile gauze bandages with the time of their reinforcement being documented. |
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When is someone legally capable to consent/Make decisions for themselves? |
When an adult is of SOUND MIND it is said they have the capacity or to be legally competent. - No learning issues/Disabilities - Of an age/level of independence - When mentally sound |
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What paperwork dictates what happens to a pt? |
Advanced care directive. |
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What are some nursing considerations when caring for a stoma? |
- Should be above skin level, red and moist. - There should also be no irritation on the skin surrounding it. - Medication can be administered for diarrhoea and constipation. - Stoma appliance should be changed regularly to avoid leakage - Should be emptied at the same time the patient empties their bladder. - Look for tears or irritation around the stoma site |
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When does a person NOT have the legal capacity to consent? |
- Unconscious - Intellectually disabled - In an emergency - Is a child/Minor - Fails a threshold test of capacity |
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When can a health professional provide consent for a pt? |
Only when it is : - 'Doctrine of necessity" - An emergency - Necessary - Reasonable - Given in good faith/Thinks the pt would wish it |
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What are nursing considerations for caring for a pt with a urinary catheter? |
- Assess the drainage system to ensure that the catheter is functioning properly. - Fluid intake and output should be recorded hourly to measure renal function and urinary drainage. - Check for any overflow - Check for obstructions - Monitor the colour, odour and volume. - Ensure that the tubing is not kinked and that the bag is below the patient for gravity drainage. |
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What is negligence? |
When you fail to deliver the best care you can. Requires: - Results in harm that was reasonably foreseeable
May be an act or NOT performing an act |
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What is age of consent in Victoria? |
18 years of age (age of Majority Act 1977) |
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What is Gillick's competency? |
15yo female who got contraceptives without her parents |
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What is an ORIF? |
Open Reduction Internal Fixation Done to improve function by restoring motion and stability and relieve pain and disability. |
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What is a crush injury? |
Occurs when a person is physically caught between opposing forces. |
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What are nursing considerations needed regarding an ORIF? |
- Assess the extent of the damage and function of the body systems. - Check vital signs and immobilise the affected area to control pain and bleeding. - Administer medications for pain. - Peripheral pulses should be assessed, especially those distal to the affected area. If a pulse is not present, it should be compared to other limbs as well to check if the issue is local or due to systemic hypotension. |
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When are the only times a human being can consent for another? |
In an emergency or is an ENDURING power of attorney |
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Is getting consent from the next of kin required legally? |
No. |
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What is another name for power of attorney? |
Enduring guardianship |
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Where must consent forms be signed? |
When with the person who gave the information regarding the procedure is PRESENT eg/ NOT when form is given from receptionist |
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Who must give information about a procedure and obtain the consent when it is required to be given in writing? |
Usually the surgeon of Attending Medical Officer (AMO) |
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Define Assault |
Cause fear of injury in another person & does not need to be explicitly expressed |
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Define battery |
Physical contact without consent, doesn't have to cause injury eg/ Dragging a pt out of bed |
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Why do we obtain consent forms? |
So a pt cannot make claims of assault and battery in regards to a procedure |
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What is duty of care? |
To work within your scope of practice while working in pts best interest
"Taking reasonable care to avoid acts or omissions that a reasonable person in a similar position should see would likely cause harm." |
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How would a court decide if someone has breached their duty of care? |
Obtaining information from : - Professional peers - Professional organizations - Employer policy - Our documentation <- IMPORTANT |
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What is the purpose of documentation? |
IF YOU DON'T DOCUMENT IT DIDN'T HAPPEN - Show what you have done with evidence - For communication between medical teams - Keep a record to avoid drug errors - Good for confused pts : flags it and lets everyone know what is going on - TO BE ABLE TO TRACK YOUR PTS PROGRESS! - Can be required in court |
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What is SOAPIE when writing nursing notes? |
Subjective Objective Assessment Plan Implementation Evaluation |
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What is DAR when writing nursing notes? |
Data (Objective and subjective
Action (intervention) Response |
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Define Acute Care |
A pattern of health care in which a pt is treated for a brief but severe episode of illness or during recovery from surgery |
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Define Surgery |
Is concerned with diseases and trauma requiring operative procedures and the treatment of disease by manipulations and incisions May be elective or emergency/urgent Can be inpatient (in hospital) or outpatient (day surgery or a doctors office) settings |
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Define Perioperative Nursing |
Perioperative nursing is a nursing specialty that works with patients who are having operative or other invasive procedures. > Pre-operative > Intra-operative > Post - Operative |
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What are the types of surgical procedures? |
Diagnostic (to diagnose or conform a diagnosis) Ablative (removal of diseased tissue/organ) Reconstructive Palliative Transplant |
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What are the three phases of the surgical experience? |
Preoperative |
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What are some preoperative risk factors (general)? |
- Age - Nutritional status - Medical/Surgical History - Medications - Lifestyle choices - Environmental - Procedural |
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What are some examples of diagnostic tests? |
- Pathology > Sputum > CT ECG Pulmonary Function tests > Used if worried about PE |
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What considerations are needed for older adults? |
Physiological changes |
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What are the roles of intraoperative nurses? |
- Pass instruments (Instrument nurse) - Scout Nurse - Scrub Nurse - Circulating nurse
- Assist anesthetist with anaesthetic - Administer meds (Anaesthetics, sedation, muscle relaxation, pain relief, prophylactic meds |
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What is RPAO? |
Routine Post-Anesthetic Observations - Vitals - LoC Assessing : - Pain - N/V - Haemostasis/Bleeding - Return to Normothermia (Normal temperature) |
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What are some post-operative complications? |
- Hypovolemic Shock - Confusion - Stroke - Pain - Haemorrage - Thrombus - DVT--> MI - Infection - Lungs can't expand enough - Atelectasis - Hypoxia - PE - Pneumonia - Embolus Constipation - Diarrhea - N/V - Paralytic Ileus - Wound infection - Wound Dehiscence - Scarring - Pressure injuries - Urine retention - Dehydration - Overload - Renal failure - Loss of mobility - Loss of strength - Loss of hormones - Hormone replacement? - Anxiety - Depression - Altered body image - Loss of control - Anger - Drug interactions/Metabolic disturbance - Respiratory depression |
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What is the WHO analgesic ladder? |
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What is TENS? |
Transcutaneous electrical nerve stimulation |
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What are some alternative therapies for pain management? |
- Music - Massage - Aromatherapy - Hot/cold packs - Acupuncture - Acupressure - Hypnosis |
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What should be included in discharge planning? |
Pt assessed for : - Home situation - Support Pt Education includes : - Pain management - Medications - Follow up appointment - Emergency/Who to contact/What to look for - Exercise/work/sexual activity/lifting/driving (When can pt resume normal activities) - Potential complications Pt should be provided with : - Referrals - Follow-up appointments booked - Take home medications and education with pharmacist |
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Define inflammation |
Body's response to injury. Start of the healing process |
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What is the purpose of inflammation? |
A. Stimulates healing
B. Cleans up dead and injured cells C. Stimulates immune response |
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Is normal tissue injured during inflammation?
What are some examples |
Yes it can be. Crohns disease, both arthritises |
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What are 5 causes of inflammation? |
- Trauma - Inflammation - Infection - Burns - Stress - Toxins - Alcohol |
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What are the cardinal signs of inflammation? |
Pain Redness Immobility (Loss of function) Swelling Heat |
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What are the two phases of inflammation? |
Vascular - Emigration of WBCs |
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Inflammation is mediated by a host of chemicals produced by what? |
Cells (Within tissues) and Plasma |
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Which of the following best describe the sequence of events in the vascular phase of inflammation?
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1. Vasoconstriction
(lasts only seconds 2. Vasodilation (increased blood flow, redness and warmth) 3. Increased vascular permeability 'Leaky capillaries' Protein-rich plasma into ICF > OEDEMA |
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What are the two types of mediators of inflammation? |
Chemical mediators - produced by cells local to injury site Components of plasma - Usually produced by the liver |
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What are the chemical mediators involved in inflammation? |
- Histamine (from mast cells) - Serotonin Neuropeptides Cytokines aka interleukins
>Thromboxane (TXA2) > Leukotrienes |
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What is the biosynthesis path of PGs fromarachidonate? |
Trauma > Phospholipidase > Arachidonic acid = |
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What do our glucocorticoids work on? |
Phospholipidases |
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What do NSAIDs work on? |
COX-1 and COX-2 |
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What are the components of plasma? |
- Compliment system Series of proteins that play an important role in immunity > Opsonization, (coats microbes to flag them) > Increased vas. permab. > Leukocyte chemotaxis - Kinin system - Coagulation system > Trap injurous agent, initiate framework for repair |
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What do leukocytes do in inflammation? |
Involved in cellular phase |
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What are the outcomes of acute inflammation? |
- Scarring/Fibrosis - Resolution - Progression to chronic inflammation |
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Define Fibrosis |
The thickening and scarring of connective tissue, usually as a result of injury. |
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What defines chronic inflammation? |
- Prolonged host response (2+ weeks) - Inflammation, healing by repair, immune response - lymphocytes and macrophages are the key cells involved - granulomas form - extensive tissue destruction eg/ Tuberculosis, Chron's disease, leprosy |
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Define granuloma |
A mass of granulation tissue, typically produced in response to infection, inflammation, or the presence of a foreign substance.
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What is granulation tissue? |
Granulation tissue is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process. Granulation tissue typically grows from the base of a wound to fill wounds. |
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What is the definition of pain? |
Sensory of emotional experience associated with either actual or potential tissue damage 2. Emotional response to pain (psychological) |
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Is pain objective or subjective? |
Subjective - only the subject of the pain can tell you what it is |
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What is the pain threshold? |
Relatively constant between everyone |
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What is pain tolerance? |
Differs between individuals |
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What factors can negatively affect pain tolerance? |
Anxiety Tired Depressed Isolated Fearful/frightened Sleeplessness Anger |
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What factors can positively affect pain tolerance? |
Sleep Empathy Medications > Analgesics > Anti-anxiety agents > Anti-depressants |
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What is Nociceptive pain? |
- From stimulation of superficial or deeo nociceptor by noxious stimuli |
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What is a common name for a nociceptor? |
Pain receptor |
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Define noxious |
Harmful, poisonous, or very unpleasant. |
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What are examples of superficial nociceptive pain? |
Somatic (Body) Best treated with NSAIDs |
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What are examples of deepl nociceptive pain? |
Visceral (Internal) eg. Organs and large muscles Best treated with opiods May be referred pain |
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What is neuropathic pain? |
Arises from legions in CNS/PNS IS NERVE DAMAGE eg/ Collapsed disc & nerve compression Associated with paraesthesia (pins and needles) and allodynia (pain from stimuli that is not normally painful) Adjunct therapy is required |
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What is psychogenic pain? |
Caused by things like anxiety, depression and fear |
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How do we perceive nociceptive pain? |
Via action potentials Modulation |
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Common name for afferent nerves? |
Sensory nerves |
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What are nociceptors? |
• located on free afferent nerve endings • detect nociceptive information • activated by noxious stimuli |
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What are some examples of noxious stimuli? |
• mechanical *trauma* • thermal *hot/cold* • chemical *acids* eg) H+, K+, prostaglandins, leukotrienes, histamine, bradykinin, CGRP, SP, adenosine |
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Which skin receptors are involved in touch ? |
Tactile (touch) copusles |
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What chemical causes angina pain? |
Adenosine |
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What skin receptor is involved in deep pressure? |
Lamellated pacinian corpuscle |
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What are the 2 types of nerve fibres transmit pain information? |
1) myelinated A(delta) fibres • fast, sharp, well-localised 2) unmyelinated C fibres • slow in onset, dull, burning |
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How does nociceptiive pain travel? |
Noxious message relayed via action potentials to Dorsal Root Ganglion (& then to dorsal horn of spinal cord) Pain > nociceptor detects > action potential along afferent nerve > spinal cord (dorsal root ganglion) > swaps sides in spinal cord cause brain needs to know about pain urgently > synapes with other internerons > |
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Where do pain messages get taken thru the spine? |
Spinothalamic pathway (between spine and thalamus) |
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Where is the sensory relay center of the brain? |
Thalamus |
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What is the limbic system for? |
Emotions
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Whats the Amygdala for? |
Memory |
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Where is all sensory information processed in the brain? |
Primary somatosensory cortex |
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What are the spinothalamic pathways? |
1) Neospinothalamic tract
• A(delta) fibres • specific pain information; little emotion • acute pain 2) Paleospinothalamic tract • C fibres • distressing; emotional • chronic pain |
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Main theory of how pain works? |
Gate control theory (main one) • stimulating touch (mechanoreceptor) neuron decreases intensity ofpain eg) bump funny bone > one pain 'distracts' from another' - only one fits on the pathway road • “spinal gate” modifies transmission of pain from spinal cord to highercentres • gate open > pain transmitted from spinal cord to higher centres • gate closed > pain intensity decreased due to stimulation of touch neuron • “gate” influenced by descending inhibition from brain |
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What is modulation in nociceptive pain? |
Occurs at multiple sites to modify pain eg) dorsal horn, midbrain, limbic system |
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What is the Association cortex? |
Any of the expanses of the cerebral cortex that are not sensory or motor in the customary sense, but instead are associated with advanced stages of sensory information processing, multisensory integration, or sensorimotor integration |
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What are endogenous opioids? |
• distributed widely in CNS • natural pain-relieving chemicals • suppress centrally controlled pain mechanisms eg) in thalamus and spinal cord B(beta)-endorphin causes analgesia, euphoria |
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Where does modulation occur? |
- Dorsal horn - Midbrain - Limbic system |
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How do we classify pain? |
- Location - Referred (including phantom) - Special types (cancer or ischemic) - Duration |
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How many months is it when we count pain as chronic? |
Over 6 months |
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Which type of pain produces autonomic responses such as : |
Acute only : Chronic pain produces NO AUTONOMIC RESPONSES |
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What types of drugs are used for Pharmacological management of pain? |
Types of analgesic drugs used 1) opioids (morphine-like drugs, narcotic analgesics) |
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What are opioids? |
Opioids include any substance that produces morphine-like effectsand that are blocked by antagonists; opium-like compound Opiates are opium derivatives Opium (Papaver somniferum) used for thousands of years to produceanalgesia and euphoria |
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Define narcotic |
Compounds causing numbness or stupor |
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What are morphine analogues? |
Closely related in structure to morphine andoften synthesised from it |
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What are the types of opioid receptors? |
(mu) receptors • analgesia, euphoria, sedation, decrease GI motility, miosis,respiratory depression, drug dependence (kappa) receptors • analgesia, sedation, miosis, dysphoria (delta) receptors • analgesia, decrease GI motility |
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Define miosis |
Pin point pupils |
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What are some actions of opioids at opioid receptors? |
1) agonists eg) morphine (full agonist) 2) antagonistseg) naloxone (Narcan) 3) partial agonistseg) buprenorphine 4) agonist/antagonistseg) pentazocine |
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Which receptors is morphine a full agonist of? |
Mu, kappa and delta |
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Which receptor is fentanyl a full agonist of? |
Mu |
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Which receptor is methadone a full agonist of? |
Mu |
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Which receptors does buprenorphine work on? |
Mu (partial) |
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Which opioid receptor is involved in dysphoria? |
Kappa |
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What are the pharmacodynamics of morphine? |
• morphine binds to opioid receptors as a full agonist(the endogenous ligand in this case are the endogenous opioidseg. endorphins) |
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How does the g-protein complex stop action potentials? |
Closes Ca++ channels |
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What are the pharmacokinetics of opioids? (Think ADME) |
• often not well absorbed after oral administration
• liver and kidney disease Pharmacokinetics of morphine Absorption • many formulations and routes of administrationeg) oral dose may need to be 2-6 times greater than parenteral dose Distribution • widely distributed Metabolism • liver Excretion • metabolites excreted by kidneys |
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What are the 'central' pharmacological effects of morphine? |
• analgesia • suppression of cough reflex • suppression of respiratory centre • sedation • euphoria • dysphoria • miosis • nausea and vomiting • hypotension and bradycardia • tolerance/dependence/addiction - formication |
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What is a 'central' effect? |
Mediated by the brain and spinal cord |
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Define formication |
A sensation like insects crawling over the skin. |
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What are the peripheral effects of morphine? |
• decreased GI motility • spasms of sphincter muscles • release of histamine (->formication) |
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What are morphine's ADR's? |
• respiratory depression • sedation • circulatory depression • nausea and vomiting • constipation • tolerance |
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What interacts with morphine? |
Alcohol or other CNS depressants |
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What are contraindications of morphine? |
• acute respiratory depression • acute alcoholism • head injury (cannot assess LOC) • acute asthma • COAD (COPD) • any respiratory impairment |
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What is codeine? |
Pharmacodynamics • weak agonist at opioid receptors Pharmacokinetics • well absorbed orally; pro-drug (in 90% of population) Pharmacological effects • analgesia, anti-tussive and anti-diarrhoeal Adverse effects • constipation • addiction |
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What is a pro-drug? |
A biologically inactive compound which can be metabolized in the body to produce a drug. |
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What is Fentanyl? How does it work? |
Pharmacodynamics • full agonist at mu receptor Pharmacokinetics • numerous formulations • short duration of action Pharmacological effects • analgesia |
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What is tramadol? How does it work? |
Pharmacodynamics • sustained-release capsules • analgesia Adverse effects • reduced incidence of respiratory depression and constipation • limited potential for addiction |
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What is naloxone? How does it work? |
Pharmacodynamics • antagonist at opioid receptors Pharmacokinetics • parenteral administration • short- half-life time (1 hour) Pharmacological effects • reverses the effects of opioid agonists Adverse effects • nausea and vomiting |
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What are some characteristis of NSAIDs? |
• most widely used therapeutic agents • all have adverse effects • include a variety of different agents and chemical classes |
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What is naltrexone used for? |
To beat opioid addiction in a supervised, clinical environment |
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What is an example of a salicycate? |
Aspirin |
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Where do you find COX-1 |
It is expressed in most cells |
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When is COX-2 formed? |
In inflammatory conditions and cancer |
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What are Prostaglandins? |
• mediators of inflammation, pain and fever • many types For example …. • PGD2 which causes vasodilatation, hyperalgesia • PGF2(alpha) which causes uterine contraction • PGE2 which causes fever, hyperalgesia |
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What do prostacyclins do? |
vasodilatation, inhibits platelet aggregation |
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What do thromboxanes do? |
vasoconstriction, stimulates platelet aggregation |
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What are the pharmacodynamics of NSAIDs |
• NSAIDS act on enzymes via competitive inhibition • NSAIDS competitively inhibit cyclo-oxygenase 1 and cyclo-oxygenase 2 (COX-1 and COX-2) > thus inhibiting prostaglandin synthesis • NSAIDSs also act as free-radical scavengers |
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WHat is an example of a NSAID that has relative selectivity for COX-1? |
indomethacin (Very strong NSAID) |
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WHat are the pharmacological effects of NSAIDs? |
• anti-inflammatory effects • analgesic effects • antipyretic effects (• antiplatelet effects) • virtually all NSAIDs have an analgesic and antipyretic effect but theinflammatory effect varies |
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What are some indications for NSAIDs? |
• mild to moderate pain • fever • inflammation caused by rheumatoid or osteoarthritis or othermusculoskeletal inflammations |
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What are some ADRs of NSAIDs? |
• GI tract disorders • asthma attacks • skin reactions • renal damage |
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What are some indications for aspirin? |
• pain and fever • rheumatic fever • rheumatoid and osteoarthritis • prevention of acute myocardial infarction and stroke |
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What are some ADRs of NSAIDs? |
• gastric erosions and bleeding • Salicylism • skin rashes • worsening for asthmatics • Reye’s disorder |
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Define salicylism |
a toxic condition produced by the excessive intake of salicylic acid or salicylates and marked by ringing in the ears, nausea, and vomiting
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What are some adverse effects of paracetamol? |
• liver (fatal) • nausea, vomiting |
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WHy do we not give aspirin to children? |
Can cause Reye's disorder
A rare but serious condition that causes swelling in the liver and brain. |
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Define general anaesthetic |
WHOLE BODY AND REVERSIBLE |
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Define Local anaesthetic |
A drug that directly induces the absence of pain sensation in thatpart of the body |
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WHat are some pre-15th century anasthetics? |
Alchohol Hemp Atropine Opiates |
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What is atropine? |
A poisonous compound found in deadly nightshade and related plants. It is used in medicine as a muscle relaxant |
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What are some anasthetics used in 1840's? |
Gaseous agents chloroform, ether and nitrous oxide |
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What are the pharmacodynamics of general anaesthesia? |
- Not fully understood, only theories - No GA receptors in the CNS
• inhibitory CNS pathways are enhanced |
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What are the theories behind how general anesthesia works? |
1) GAs act at GABA receptors • Cl- channels open, Cl- influx • inside of cell becomes more negative • CNS depression • hyperpolarisation • CNS depression 3) GA act at NMDA receptors • Ca2+ channels close, no Ca2+ influx • inside of cell stays negative • CNS depression |
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What is an NMDA receptor? |
N-methyl-D-aspartate receptor (also known as the NMDA receptor or NMDAR) Is a glutamate receptor and ion channel protein found in nerve cells |
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What are the four stages of general anaesthesia? |
Analgesia Excitement Surgical Analgesia Medullary Paralysis |
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Hiw can general anaesthetics be given? |
Via inhalation or IV |
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What is TIVA? |
Total IV Anaesthesia
Can be defined as a technique of general anaesthesia using a combination of agents given solely by the intravenous route and in the absence of all inhalational agents including nitrous oxide. |
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Which anesthetic is used for induction? |
Propofol |
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Which anesthetic is used for maintenance? |
Nitrous Oxide and sevoflurane/methoxyflurane |
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What are the pharmacokinetics of inhaled general anesthesia? |
• absorption occurs in lungs and is dependent on partial pressures • lung function critical for effective use • agents that are lipid soluble transfer to CNS at quicker rate • rapid recovery can occur after administration ceases • MAC (minimum alveolar concentration) |
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What is MAC? |
Minimum Alveolar Concentration |
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What is Nitrous oxide administer with? |
• administered with oxygen via hudson mask • better analgesic than anaesthetic • combined with other inhaled anaesthetics (and oxygen) |
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What are the indications for nitrous oxide? |
• minor surgery - maintenance of GA - obstetric analgesia - dentalsurgery |
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What are the ADRs for nitrous oxide? |
• mild cardiac depression - nausea and vomiting |
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What is the drug of choice for induction and maintenance of GA (general anasthesia)? |
Sevoflurane |
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What are the adverse effects of sevoflurane? |
- cardiac and respiratory depression
- shivering - salivation - postoperative nausea and vomiting (PONV) |
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What are examples of fluorinated hydrocarbons? |
sevoflurane methoxyflurane (penthrox) |
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What are the two major groups of IV anaesthetics? |
• ultra-short acting barbiturates eg) thiopentone • non-barbiturates eg) propofol, ketamine |
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What are the pharmacokinetics of IV anesthetics? |
• highly lipid soluble • rapid onset of action |
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What is the indication for propofol? |
• induction and maintenance of GA |
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What are the ADRs for propofol? |
• nausea and vomiting - respiratory and cardiac depressant |
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What are Clinical considerations for a pt under GA? |
1) Balanced anaesthesia • induction of anaesthesia using a combination of drugs Typical drug regimen for a surgical procedure a) Pre-medication *not essential* • benzodiazepines to decrease anxiety eg) midazolam, flunitrazepam • anticholinergics to decrease secretions eg) atropine, glycopyrrolate • analgesics to prevent pain eg) morphine, fentanyl b) Induction of GA• IV propofol c) Maintenance of GA • inhaled N2O/sevoflurane d) Analagesia • morphine, fentanyl, alfentanil |
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What is Neuroleptanalgesia? |
• state of deep sedation, analgesia and amnesia • neuroleptic (anti-psychotic) and opioids • not popular anymore |
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What are some post-operative drugs? |
• antiemetics • analgesics (plus antagonist if opioid toxicity) • antiplatelet and anticoagulants |
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Define Local anaesthesia |
A drug that directly induces the absence of pain sensation in thatpart of the body |
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What has been used in the past for local anaesthesia? |
Cocaine |
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What modern drugs are used for local anaesthesia? |
- lignocaine - bupivacaine - ropivacaine |
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What is the pharmacodynamics of local anaesthetics? |
LAs block voltage-gated Na+ channels in excitable cells |
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|
What are the two main types of fracture? |
Open and closed |
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What are the types of fractures |
- Comminuted fracture (crushed/splintered) - Greenstick - Compression - Epiphysial - Spiral - Transverse - Linear - Nondisplaced/Oblique (slanting) |
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What is a 'reduction' |
Setting the bone - reducing the 'space' so the bone can heal |
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How long does it take until you can weight bear after a closed reduction? |
7-10 days |
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What is an external fixator? |
A steel scaffold outside of a leg to maintain bone alignment - Poor mobility |
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What is internal fixation |
When a bone has something to hold it together internally such as with plates or screws |
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What type of bone breaks get ORIFs? |
Comminuted or open |
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How long after an ORIF can you partial weight bear? |
4-6 weeks |
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WHat happens in an ORIF? |
- Fracture exposed - Fragments aligned - Bones held in place with metal screws above and below the break |
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What are some adverse reactions to getting an ORIF? |
- Metalwork may cause symptoms - Anything open increases infection risk - Long healing time 96-10 weeks if young and healthy) |
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What are the local anaesthetic pharmacokinetics? |
• agent to act on area of administration • local disposition • formulated with adrenaline (NB: exceptions; end arteries) |
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What are the ways to apply local anaesthesia? |
1) Topical (surface) anaesthesia • application to skin or mucous membrane via spray, solution, cream eg) EMLA (eutectic mixture of LA) cream 2) Infiltration anaesthesia • injection of LA into tissue to be anaesthetisedeg) skin lesions, skin incisions, draining cyst 3) Peripheral nerve block anaesthesia • LA injected into the vicinity of nerve trunkeg) foot, hand and eye surgery eg) obstetric procedures eg) postoperative pain 4) Epidural anaesthesia • LA injected into the space between the dura mater and ligamentumflavum (spinal cord levels C7-T10) eg) obstetric procedures eg) urology, thoracic, abdominal, perineal surgery 5) Spinal • LA injected into the CSF in subarachnoid space eg) lower abdomen and extremities |
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What are the pharmacological effects of a local anaesthetic? |
• LAs are capable of affecting all excitable membranes • pain sensation abolished • loss of temperature, proprioception, touch and pressure |
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Define proprioception |
The ability to sense stimuli arising within the body regarding position, motion, and equilibrium. |
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When was the first record of disinfection |
450 BC |
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Who pioneered the idea of asepsis? |
Lister |
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What are the indications for local anaesthesia? |
• local anaesthesia • postoperative analgesia • anti-dysrhythmic (lignocaine) |
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Which century did many major surgical innovations occur? |
19th |
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What are some major things that need to be considered in the operating room? |
- Pt safety - Infection control - Efficiency - Privacy |
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What are the areas of the operating department? |
- CSSD (Central Sterile Services Department)
- Day procedure unit -Holding Bay - Anaesthetics - Intra-operative/Operating room - PACU - Stores |
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What is an ADR of local anaesthetic? |
- Potentially toxic very quickly - Local complications eg/ Inflammation - Psychogenic reactions eg/ N/V • local effects of vasoconstrictor eg) ischaemia • systemic effects of vasoconstrictor eg) sympathetic stimulation • reactions specific to epidurals and spinal LAs eg) headache, infections, hypotension • allergies eg) bronchospasm • systemic effects after LA absorption eg) visual disturbances, CNS stimulation then depression, CV andrespiratory depression |
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What are some team members that are in the operating room? |
- Anaesthetist - Anasthetic nurse & technician - Surgeon - Surgery students - Instrument nurse - Radiologist/Radiographer - Circulating nurse |
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What is CSSD? |
Central Sterile Services Department
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What is the most important thing in theatre? |
Maintaining sterility! PREVENTING CROSS CONTAMINATION! - Instruments - Stock - All areas |
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How is sterility demonstrated? |
- Expiry date - Enclosed/Taped - Not damp - When breached, its NOT USED |
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WHat are some dangers to staff in an operating room intra operatively? |
- Dangerous drugs - Sharps - Electricity + fluids - Volatile gases - Radiation - Lasers |
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How can you maintain a safe environment? |
- Vigilance
- PPE - Scavenging system - Monitoring - Instrument counting - Infection control |
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Why is there wiring shelving in a theatre? |
Prevent dust build up |
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What is the biggest cause of bacteria in a theatre? |
Humans |
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What are examples of theatre attire? |
- Fresh scrubs - Covers on dedicated work shoes - Hair covering (hat/net) - No jewellery below elbows - No false nails - Masks |
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What is surgical conscious? |
Speaking up when there is a breach of sterility |
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What is the definition of vomiting? |
Forceful expulsion of contents of stomach and upper GI throughmouth |
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What PPE will you need if there are lasers? |
Specialised goggles |
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What is scavenging? |
A system to remove volatile gases and smoke (eg/ pt anaesthesia) from a room |
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What is a BIS? |
Bispectral Index Score Monitors sedation/consciousness level. Avoids pt 'waking' or becoming 'aware' during surgery and shows if drugs are still working |
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What do we monitor in our pt in theatre? |
- Haemodynamic status - Oxygenation - Sedation level - Gas delivery |
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When do instrument counts occur? |
- Before surgery - At close of cavity - Layers of tissue are being closed (the outside) |
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What is counted in an instrument count |
EVERYTHING including gauze and cotton buds and anything gathered during surgery (circulating nurse records what is brought in) |
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What is involvled in vomiting/why do we do it? |
• complex and coordinated reflex involving multiple nerve pathwaysand neurotransmitters • protective mechanism • strongly associated with nausea • severe cases may cause fluid and electrolyte disturbances |
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Define general anaesthetic |
"the absense of sensation and consciousness induced by various anaesthetic medications' |
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Who can administer general anaesthetic |
Anaesthesiologist Anasthesia Assistant Certified Registered Nurse Anaesthetist |
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What two main areas regulate vomiting? |
The CTZ/ Chemoreceptor Trigger Zone
Emetic Center (Brain) |
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Where is the CTZ located? |
At the base of the 4th ventricle (near where skull meets skull - cerebellum)
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What is the CTZ's role |
• can detect noxious chemicals in blood BUT not able to directly induce vomiting |
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Why do we not use ketamine as often? |
More ADRS than other general anaesthetics |
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What are some aspects of general anaesthetic? |
- Analgesia - Amnesia - Muscle Relaxation - Control of vital signs - Unconsciousness |
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What is Midazolam used for? |
To induce amnesia and to sedate short term |
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What is the CTZ stimulated by? |
- 5-HT from afferent pathways from stomach and small intestine - various smells - strong emotion - severe pain - raised ICP (intercranial Pressure) - motion sickness (labrinthine disturbances) - endocrine disturbances - toxic reactions to drugs - GI disease - treatment for cancer |
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What is ICP? |
Intercranial Pressure |
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Name two drugs that cause LOC? |
Midazolam and Propofol
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What drug class is fentanyl? |
Opioid |
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Why do we give oxygen during anaesthesia? |
Anaestesia causes hypoventilation
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Why do we only give muscle paralyzing agents during induction but only one the pt is unconscious??? |
Because if they lose control while conscious and have issues breathing due to muscles relaxing it would be very scary! It would panic the pt. |
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What medication can help a surgeon cut into the abdominal muscles? |
Muscle relaxants |
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What can help us place an ETT? |
Muscle relaxants as we get less resistance placing it in the airway |
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What is an ETT? |
Endotracheal Tube |
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What is the main difference between depolarising and non-depolarising muscle relaxants? |
Depolarising are NON REVERSIBLE and normally only used in emergencies |
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What are some examples of non-depolarising muscle relaxants? |
Atracurium Rocuronium Vecuronium |
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How long does suxamethonium last? |
3-5 min |
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What side effect post-op is common for suxamethonium? |
Muscle soreness |
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How long is onset of action for suxamethonium? |
30 seconds |
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What allergy is dangerous to have in a theatre and should always be checked? |
Latex |
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What is the emetic centre? |
• induces vomiting • located in medulla (brainstem) • cannot detect noxious chemicals in blood • receives afferent input via neurotransmitters from: 1) CTZ 2) vestibular apparatus 3) GI tract 4) higher centres (pain, sight, smell) 5) other organs eg) heart , testes |
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What is the vestibular apparatus? |
THE INNER EAR
The vestibule and three semicircular canals of the inner ear. |
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Why does temperature drop when we are on a muscle relaxant? |
Cannot shiver to raise temperature |
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What chemical mediators does the CTZ send to activate to the emetic centre? |
- ACh - Histamine - Dopamine |
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What is the efferent part of vomiting regulation and where does it come from? |
The emetic center sends out messages to the abdominal muscles to contract |
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What is the afferent part of vomiting regulation include? |
Any messages into the CTZ and the emetic centre. |
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What are the mechanics of vomiting? |
Vomiting sends out message to : Abdominal muscles > contract > Increase abdominal pressure > Stomach contents passes into oesphagus/mouth > contents are expelled |
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What are the 5 types of antiemetic agents? |
NOTE: ALL ARE ANTAGONISTS OR ANTI • benzodiazepines (calming) • ginger • sugar solution |
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How do dopamine antagonists work? |
• bind to dopamine2 receptors in CTZ; thus blocking dopamine • certain dopamine antagonists also act as antimuscarinics andantihistamines Example: metoclopramide |
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What is an example of a anti emetic dopamine antagonist? |
Metoclopramide |
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How does metoclopramide work? |
• centrally blocks dopamine (D2) receptors in the CTZ • high doses 5-HT3 antagonism in CTZPharmacokinetics • oral or parenteral • extensively metabolised in the liver |
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What are the indications for Metoclopramide? |
• gastroparesis, gastro-oesophageal reflux • prevention of nausea and vomiting from emetogenic cytotoxic drugs,radiation and opioids • GI radiological examinations |
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What are the ADRs of metoclopramide? |
- Diarrhoea - Sleepiness - Headache - Parkinsonian effects - Bradycardia |
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What are some contra-indications for metoclopramide? |
- Parkinsons disease - Depression |
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What is an example of an anti-emetic muscarinic antagonist? |
Hyoscine / hydrobromide |
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What are the pharmacodynamics of hyoscine? |
Binds to muscarinic receptors in vestibular apparatus and vomitcentre; this blocking acetylcholine |
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What is an indication for hyoscine (muscarinic antagonist)? |
Motion Sickness (its the ingredient in Travacalm) |
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What is an example of an anti-emetic anti-histamine? |
Pheniramine (Avil) |
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|
What are the pharmacodynamics of pheniamine? |
Bind to H1 receptors in vomit centre and vestibular apparatus; thusblocking histamine |
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What is a H1 receptor? |
A histamine receptor |
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|
What are indications for pheniramine? |
Motion sickness Ménière’s disease Labyrinthitis |
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|
What is Ménière’s disease? |
Disease of unknown cause affecting the membranous labyrinth of the ear, causing progressive deafness and attacks of tinnitus and vertigo. |
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What is Labyrinthitis? |
Inflammation of the labyrinth or inner ear. |
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What is an ADR of pheniramine? |
Drowsiness |
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|
What are the ADRs of hyoscine? |
- Dry mouth - Thirst - Vision disturbances - Constipation - Tachycardia |
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|
What is an example of a 5-HT3 antagonist? |
Ondansetron |
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|
What are the pharmacodynamics of ondansetron? |
Binds to 5-HT3 receptors in : - CTZ - GI tract (via vagusnerve) |
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|
What are some indications for ondansetron? |
Post operative nausea in adolescents (Can't give them metoclopramide) |
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|
What are some ADRs of ondanstron? |
- Constipation - Headache - Dizziness - Anxiety |
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|
What are some drug interactions of ondansetron? |
- Tramadol |
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|
What is a contra-indication of ondansetron? |
Liver impairment as it is primarily eliminated via hepatic metabolism
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|
What is an example of a neurokinin-1 Antagonist? |
Aprepitant |
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|
What are some indications of aprepitant? |
Vomiting associated with moderate-high, emetogenic, cytotoxicdrugs |
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|
What are some ADRs of aprepitant? |
- Hiccups - Headache - Anorexia - Constipation |
|
|
What ratio of people in Australia get colorectal cancer? |
1:21 |
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|
What is colorectal cancer? |
Cancer of the caecum, colon or rectum |
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|
What age is at an increased colorectal cancer risk? |
40-50+ |
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|
Name some signs/symptoms of colorectal cancer |
- Blood in stool - Constipation - Pain - Changes in bowel habits |
|
|
What are some risk factors for bowel cancer? |
- Obesity - Low activity/Physical inactivity - High saturated fat diet - Family history - Genetic suseptibility - Medical and iatrogenic factors |
|
|
Define iatrogenic |
relating to illness caused by medical examination or treatment. |
|
|
How do you diagnose bowel cancer? |
FOBT |
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|
What is FOBT? |
Faecal occult blood test |
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|
What ages do you do a FOBT? |
50, 55, 60, 65, 70, 74 but if there is a family history it should be done every 2 years |
|
|
What are the pros/Cons of a colonoscopy? |
- Can detect 95% of cancers - A biopsy may be taken - One or more polyps may be removed - Small risk of perforation |
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|
How do we treat bowel surgery |
Surgery - Bowel resection with anastomosis ± temporary colostomy - Abdominoperineal resection with colostomy - Construction of a coloanal (J) pouch Chemotherapy + antibody treatment >Target growth factors involved in tumour formation |
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|
What is a Bradma label? |
Patient label to put onto patient forms |
|
|
What type of blood tests could you do before an abdominoperenial resection? |
Full blood count (FBC), electrolytes, urea, creatinine (EUC),coagulation studies, liver function test (LFT), cross-match(group and hold)
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|
When is fluid considered 'balanced' on a chart? |
When the average daily output = average daily input |
|
|
Name 3 homeostatic mechanisms that kick in during cases of hypovolemia |
Fluid shift ADH release Renin-angiotensin-aldosterone system (RAAS) |
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|
What are the signs and symptoms of dehydration? (clinical manifestations) |
- Dry lips /mouth - poor skin tugour - halitosis - affected sensation - sunken eyes - sense of thirst - headaches - Increased HR - Decreased BP - Increased RR - Electrolyte imbalances - Dry mucous membranes |
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|
What infusion is most commonly given in the case of dehydration? |
an isotonic crystalloid |
|
|
What is an example of an anxiolytic? |
Benzodiazepines > Diazepam |
|
|
What type of anti biotics is best used prophylactically? |
Gram-negative antibiotics |
|
|
Which best describes osmosis? |
Movement of water from a low solute concentration to a high solute concentration |
|
|
What occurs after physiological release of antidiuretic hormone (ADH)? |
Increased water reabsorption in the renal tubule |
|
|
Which occurs after physiological release of renin |
- Increased plasma volume - Vasodilation - Decreased preload |
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|
What happens when a cell is placed in a hypotonic solution |
The cell shrinks |
|
|
What are some causes of oedema? |
Sodium retention Increased hydrostatic pressure Decreased colloid pressure Physical trauma |
|
|
What percentage of the human body is water? |
Approx 60% |
|
|
What two fluids make up our total body water? |
Intracellula and Extracellular fluids
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|
|
What are our two types of extracellular fluid? |
Plasma (3L) |
|
|
Define interstital fluid (IF) |
Fluid that bathes our cells and tissues
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|
|
Give some examples of fluid output |
- Urine - Sweat - Tears - Breath - Faeces |
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Give some examples of fluid input |
- Foods - Fluids - Water - IV line - From metabolic reactions |
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What is the purpose of fluid in our body? |
- Bathe our fluids - Remove wastes - Allow adequate perfusion to occur - Allows oxygen and glucose circulate |
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What bodily systems are affected when there is fluid imbalance? |
All of them! |
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Define Diffusion |
Movement of liquids or gases through a semi-permeablemembrane from an area of high concentration to low concentrationuntil equilibrium |
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Define Tonicity |
- Muscle tone - patterns of tones or stresss in speech - measure of dissolved particles in a solution |
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Define Osmosis |
WATER going high concentration to low (more room!) |
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Define Osmolality |
Solute concentration per kilogram of water within a compartment |
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What is the normal osmolality in a human? |
280-294 mOsm/kg |
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What does alterations in body fluid balance result in? |
Fluid deficits or Fluid excesses |
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Define fluid deficit |
• fluid intake falls below fluid output • hypovolaemia |
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What is the aetiology of fluid deficit? |
Decreased fluid intake and/or increased fluid output |
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Define aetiology |
the cause, set of causes, or manner of causation of a disease or condition.
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What are some examples of conditions that can attribute to fluid deficit? |
- Dehydration - Haemorrhage - Diarrhoea - Vomiting - Burns |
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What are risk factors for fluid deficit? |
• age • high altitude, humid/hot climate • chronic illness • certain medications |
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What is the pathogenesis of fluid loss? |
Fluid loss > Compensatory mechanisms triggered = - ADH release - RAAS activation |
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What is a simple way to define fluid shift? |
Water being pulled out from cells to compensate for low water in ECF > ECF Osmotic pressure rises > cells lose H2O to ECF via Osmosis and cells SHRINK |
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What is the order of events involved in ADH release? |
Water deprivation/loss > Osmoreceptors in the hypothalamus activated > ADH release from posterior pituitary > Increased water channels in distal tubule and collecting duct > Increased water reabsorption |
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What is the order of events involved in RAAS? |
- decreased pressure in renal arteries ( CO) - decreased glomerular filtration rate - increased sympathetic activity > Circulares past lungs where ACE is > Angiotensin I turns into Angiotensin II |
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What happens from fluid deficit? (Pathologies) |
• hypovolaemia • decreased CO • poor organ perfusion • renal failure • circulatory shock |
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How do you treat fluid deficit? |
1) Treat the underlying cause 2) Selection of appropriate fluid replacement 3) Treat of other symptoms eg) oxygen for low RR 4) Continuing assessment 5) Complications of fluid replacement |
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What must be considered when selecting a treatment method for fluid deficit? |
• Route (oral versus parenteral) • tonicity of replacement fluid • compensatory mechanisms • deficit displacement (oedema) • restoration of losses |
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What are some complications of fluid replacement? |
• circulatory overload • anaphylaxis • haemostasis issues • renal failure • metabolic acidosis |
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Define metabolic acidosis |
A condition that occurs when the body produces excessive quantities of acid or when the kidneys are not removing enough acid from the body. |
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What are the adverse effects of administering a hypotonic solution IV? |
- hypotension - cellular oedema - tissue damage |
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What is the osmolarity of a hypotonic solution? |
< 250mOsm/L |
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What is the osmolarity of a hypertonic solution? |
> 330mosm/L 20%+ of dextrose |
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Why give a hypertonic solution? |
relieves cellular oedema |
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What are the ADRs of a hypertonic solution? |
- Risk of volume overload - Hyperglycaemia - Osmotic Diuresis |
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Define Osmotic Diuresis |
is increased urination caused by the presence of certain substances in the small tubes of the kidneys. The excretion occurs when substances such as glucose enter the kidney tubules and cannot be reabsorbed |
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Name 3 types of IV fluids |
1) Crystalloids
2) Colloids 3) Blood/blood products |
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Define crystalloids |
• IV fluid and electrolytes • fluid distributes evenly |
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Give examples of isotonic crystalloids |
- 0.9% Saline - Hartmann’s Solution - 5% dextrose inwater |
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|
Give examples of colloids |
- Albumin - Mannoitol - Gelatins - Dextra - Heta-starch |
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What is generaly the tonicity of a colloid solution? |
Hypertonic |
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What are colloids? |
• plasma expanders • contain particles (protein, sugar or starch) • Usually hypertonic and makes fluid moves from interstitial & intracellular space to intravascularspace |
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What are 3 blood products? |
• whole blood • packed cells • fresh frozen plasma |
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Define fluid excess |
One or more body compartments that is inundated with fluid • hypervolaemia • commonly oedema |
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Define Oaedema |
increased fluid in the interstitial tissue spaces |
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Give some examples of oedema |
- hydrothorax - hydropericardium - ascites - anasarca |
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Define anasarca |
extreme generalized edema, is a medical condition characterized by widespread swelling of the skin due to effusion of fluid into the extracellular space. |
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Define Ascites |
the accumulation of fluid in the peritoneal cavity, causing abdominal swelling |
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What types of oedema are there? |
Types of oedema 1) inflammatory oedema (by trauma) • increased vascular permeability • exudate (protein-rich) 2) non-inflammatory oedema |
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What are the functions of the capolary in regards to the distribution of the ECF? |
1) Diffusion of nutrients and wastes 2) Distribution of ECF - bulk flow of protein-free plasma • distribution of fluid between interstitial fluid and plasma is not fixed • interstitial fluid can provide/receive fluid from plasma • capillary wall highly permeable to water and solutes (not protein) -> concentration of solutes in plasma = filtrate (except protein) |
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What do we refer to as non-protein solutes within plasma? |
Filtrate |
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What are the 4 fources across the capilary wall? |
1. capillaryhydrostaticpressure (Pc) 2. interstitialfluidhydrostaticpressure (Pif) 3. osmoticforce due tointerstitialplasma proteinconcentration (πp) 4. osmoticforce due toproteinconcentration (πif) 2x protein, 2x hydrostatic. One of each in or out of vessel |
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How does capillary filtration work? |
• hydrostatic pressure difference across capillary wall • bulk flow of protein-free plasma from capillary to interstitial fluid • plasma within capillary and interstitial fluid contain large amountsof crystalloids eg) sodium , chloride, glucose • no significant water concentration difference is caused by thepresence of crystalloids across capillary wall |
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What is filtration? |
the action or process of filtering something.
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How does absorption work? |
• plasma proteins (colloids) are high concentration in plasma, and lowconcentration in interstitial fluid > water concentration of plasma is lower than interstitial fluid >water flows (via osmosis) from interstitial fluid back into plasma
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What is a summary of distribution of ECF? |
1) difference between capillary hydrostatic pressure and interstitialfluid pressure favours movement of fluid out of the capillary 2) water concentration difference between plasma and interstitialfluid (which results from differences in protein concentration) favoursmovement of fluid into the capillary • exit of fluid from the arteriole end is balanced by inflow of fluid at thevenule end • excess fluid drained by lymphatics |
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|
Why does bulk flow occur out of a capillary? |
Capillary hydrostatic pressure is higher than ECP hydrostatic pressure (By about +10mmHg) |
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|
What makes water move back into a capillary? |
Osmosis (higher ECF hydrostatic pressure at venue end) (capillary @ -10mmHg in comparison) |
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|
What are the 4 things that contributes towards etiology of oedema? |
1) increased hydrostatic pressure 2) reduced plasma osmotic force pressure 3) lymphatic obstruction 4) sodium retention |
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What is the pathogenesis of increased hydrostatic pressure oedema? |
increased hydrostatic pressure eg) CCF, constrictive pericarditis, thrombosis > fluid moves out of capillary > increased venous hydrostatic pressure opposes influx at venule end >increased fluid in interstitial tissue spaces = oedema |
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What is the pathogenesis of Reduced plasma osmotic pressure oedema? |
Reduced plasma osmotic pressure
eg) nephrotic syndrome, cirrhosis, malnutrition > decrease concentration of plasma proteins > as fluid move outs of capillary, lower osmotic force to pull it back in > lymphatics cannot cope with extra drainage > increased fluid in interstitial tissue spaces = oedema |
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What is the pathogenesis of Lymphatic obstruction oedema?
|
Lymphatics blocked, fluid from ECF remains in ECF
eg/ Neoplastic obstruction, Inflammatory obstruction |
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|
Define Neoplastic obstruction |
A new and abnormal growth of tissue in a part of the body, especially as a characteristic of cancer, which is obstructing a function of the body (Eg/ lymphatic flow) |
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|
What is the pathogenesis of Sodium retention?
|
• increasing capillary hydrostatic pressure
eg) excess intake, increased renal reabsorption |
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|
What is a clinical manifestation of pulmonary oedema? |
tachypnoea, dyspnoea & moist (fine) crackles |
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|
How do we treat oedema? |
• treat cause • fluid/Na+ restriction • restrict oral intake • elevate oedematous legs & arms • diuretic administration • ↓ gastric feeding rate (change to a higher calorie feed) • ↓ IV therapy rate |
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|
What are the normal electrolyte ranges in the ECF? |
Sodium 135-145 mmol/L Potassium 3.5-5.5 mmol/L Calcium 2.2-2.6 mmol/L Magnesium 0.7-1.3 mmol/L Phosphate 0.5-1.5 mmol/L |
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|
What are the normal ranges for electrolytes in the ICF? |
Sodium 15-20 mmol/L Potassium 150-155 mmol/L Calcium 0.5-1 mmol/L Magnesium 14-15 mmol/L Phosphate 33-35 mmol/L |
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Which electrolytes are higher in the ECF than the ICF? |
Sodium and Calcium |
|
|
Which electrolytes are higher in the ICF than the ECF? |
Potassium, Magnesium and Phosphate |
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|
What are examples of conditions assosicated with electrolyte imbalances? |
- Hyponatraemia |
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|
Define Hyponatraemia |
serum [sodium] below the lower limit of normal |
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|
What is the aetiology of hyponatraemia? |
• gaining relatively more water than salt eg) excessive ADH • loss of relatively more salt than water eg) diuretics |
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What is a clinical manifestation of hyponatraemia? |
CNS dysfunction • malaise • headache • N & V • seizures • coma |
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|
Define malaise |
a general feeling of discomfort, illness, or unease whose exact cause is difficult to identify. |
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What is Hypernatraemia? |
serum [sodium] above upper limit of normal
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What is the aetiololy of Hypernatraemia? |
• gain of relatively more salt than water
eg) tube feeding • loss of relatively more water than salt eg) prolonged emesis, diarrhoea or diaphoresis without waterreplacement |
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Define diaphoresis |
sweating, especially to an unusual degree as a symptom of disease or a side effect of a drug.
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What are some clinical manifestations of hypernatraemia? |
• CNS dysfunction • lethargy • confusion • seizures • coma |
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|
Define Hypokalaemia |
decreased potassium ions in ECF |
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|
What is the aetiology of Hypokalaemia? |
• decreased potassium intake eg) anorexia • shift of potassium from ECF to cells eg) alkalosis • increased potassium excretion eg) diuretics, diarrhoae, diaphoresis |
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|
What are the clinical manifestations of Hypokalaemia?
|
• skeletal, smooth and cardiac muscle dysfunction
• weakness • diminished bowel sounds • dysrhythmias |
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|
Define hyperkalaemia |
increased potassium ions in ECF |
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|
What is the aetiology of hyperkalaemia? |
• increased potassium intake eg) excessive or too-rapid IV potassium infusion • shift of potassium from cells to ECF eg) acidosis, prolonged strenuous exercise • decreased potassium excretion eg) potassium-sparing diuretics, oliguria |
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|
What are the clinical manifestations of hyperkalaemia? |
• skeletal, smooth and cardiac muscle dysfunction
• paralysis • intestinal cramping • dysrhythmias • cardiac arrest |
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|
Define Infection |
Invasion and multiplication of pathogens into body tissues the process of infecting or the state of being infected. |
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Define Colonization |
The localization presence of microorganisms in body tissues. Can be native flora (eg/ in the gut) or foreign bacteria. |
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Define Bacteraemia |
VIable bacteria in the circulatory system. Normally killed quickly by body's immune system |
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Define Septicaemia |
Systemic inflammation caused by circulating multiplying microorganisms Blood poisoning, especially that caused by bacteria or their toxins. |
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Define Sepsis |
A syndrome that has multiple organ involvement that is the result of septicaemia. |
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|
Name the 5 types of microorganisms |
Bacteria Viruses Protozoa Fungi/yeast/moulds Helminths/worms |
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|
What are infectious diseases caused by? |
Microorganisms |
|
|
What are some characteristics of bacteria? |
- Rigid cell wall - Small - Can independently survive - No nucleus - Usually unicelluar - are gram + or gram - |
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|
What defines if bacteria is gram - or gram +? |
The amount of peptidoglycan in the cell wall |
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|
What are the characteristics of a virus? |
- Small - No cellular structure eg/ Small pox, HIV |
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|
What are the characteristics of a protozoa? |
- single celled - usually motile eg/ gardia, malaria |
|
|
What are the characteristics of a fungi/yeast/mould? |
- have a true nucleus - single or multicelled eg/ candita , ringworm |
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|
What are the characteristics of a helminth? |
- have a true nucleus - multicelled eg/ hook worm , tape worm |
|
|
What are the types of antimicrobial agents? |
Antibiotics (antibacterials) Antimycobacterials (TB, leprocy) Antifungals Antivirals |
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|
Define antibiotics |
Chemical substances produced from microorganisms that kill orsuppress the growth of other microorganisms Can be natural, synthetic or semi-synthetic |
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|
What are the Determinants of antibiotic success? |
• host’s defence mechanisms • sufficient concentration of drug at infection site • bacterial load • phase of bacterial growth • MIC of antibiotic • time that drug stays above MIC over dosing period • reducing the emergence of resistant microbial strains |
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|
What are examples of immunocompromised people? |
- On chemotherapy - Suffers from autoimmune diseases eg lupus and HIV - T2DM - Renal issues |
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|
What is the Mechanism of antibiotic action? |
ACCESS, STOP, KILL
• exerts bacteriostatic effectseg) inhibit bacterial cell growth • exerts bactericidal effectseg) cause bacterial cell death and lysis |
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|
What are the two types of specific immune response? |
- Cell mediated immune response - Antibody mediated immune response |
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|
Bacteriostatic and bactericidal effects are achieved by what? |
• inhibiting bacterial cell wall synthesis
STARVING IT BY : • inhibiting synthesis of essential metabolites |
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|
What is MIC? |
Minimum Inhibitory Concentration |
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|
Why are T2DM susceptible to infection? |
- Bacteria love glucose - Glucose makes WBC deaf, dumb and blind - cannot work properly or pick up on chemotaxic signals. |
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|
What is a drug that is classified as both bacteriostatic and bactericidal effects? |
Tetracycline |
|
|
Why do cells lyse when the membrane is broken? |
Because tonicity is different inside and outside of a cell |
|
|
What are some principles that guide optimal use of antimicrobials? |
• never treat viral infection with antibiotic • use antibiotics when spontaneous resolution is unlikely • take time to identify infecting organisms; determine susceptibility and target it • use drug with narrowest spectrum of activity • use single drug unless combination therapy is indicated • use dose of drug that is high enough to ensure efficacy withminimal toxicity and reduces the likelihood of resistance • use short duration of treatment |
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|
What are the categories of antibiotics? |
1) Inhibitors of bacterial cell wall synthesis 2) Inhibitors of bacterial protein synthesis 3) Inhibitors of DNA synthesis 4) Miscellaneous antimicrobials |
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|
What are some examples of inhibitors of bacterial cell wall synthesis? |
• penicillins eg) amoxycillin • cephalosporins eg) cephalexin • carbapenems eg) ertapenem • glycopeptides eg) vancomycin |
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|
What are penicillins? |
• derived from several strains of common mould
• most effective and least toxic antimicrobial drugs • beta-lactam ring essential to activity of drug (resistant bacteria possess beta-lactamase enzymes that renderantibiotic useless) |
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|
What are the pharmacodynamics of penicillins? |
• inhibit transpeptidase enzymes
• bactericidal; time-dependent • generally more active against gram +ve bacteria than gram –vebacteria |
|
|
How is a bacterial wall structured? |
• bacterial cell wall is a rigid cross-linked structure composed ofpeptidoglycan • transpeptidase enzymes help to cross-link cell wall strands |
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|
What are the categories of penicillins? |
1) narrow spectrum penicillins eg) penicillin G, penicillin V 2) narrow spectrum penicillinase-resistant penicillin eg) dicloxacillin, flucloxacillin 3) moderate-spectrum beta-lactamase-sensitive aminopenicillinseg) amoxycillin, ampicillin 4) broad- and extended-spectrum penicillinseg) piperacillin |
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|
What are the pharmacokinetics of penicillin? |
• certain oral penicillins are affected by gastric acid • care with IV administration; rapid infusion can cause seizures • antibiotic-dependent • renal excretion <- all anti-biotics have SIGNIFICANT levels of renal excretion |
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|
What are the Pharmacological effects of penicillins? |
cell lysis and death |
|
|
Is it penicillin or penicillinS? |
Plural - it is a family NOT a singular drug |
|
|
What are the ADRs of penicillin? |
- diarrhoea - nausea - vomiting - headache - Candida infections - allergic reactions - hives |
|
|
What is the only real reason you would give antibiotics for a viral infection? |
Because the viral infection immunocomprimises the person they are more likely to get a bacterial infection so sometimes anti bacterials are given prophylactically. |
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|
What are some drug interactions with penicillins? |
• allopurinol (rash risk) • antiplatelet drugs (bleeding) • combined oral contraceptives (Decreased effectiveness of the Pill) • NSAIDs ((GI bleeding) |
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|
What is a contraindication for peniciliins? |
- Allergic - People with Na-restricted diets - Poor kidney or CVS function |
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|
What are the two most important clinical considerations regarding penicillins? |
Anti biotic resistance |
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|
What penicillins are good for antibiotic resistance? |
• beta lactamase-resistant penicllins eg) dicloxacillin • adjuncts for greater protection against beta lactamases eg) clavulanic acid |
|
|
Why are penicillin allergies so dangerous? |
• antibiotics are derived from nonhuman sources and cause a strongimmune response • 10% population allergic to penicillins >0.01% have serious anaphylaxis • cross-reactivity with other beta lactams; cephalosporin andcarbepenem groups also contraindicated - means more chance of allergies |
|
|
Define anaphylaxis |
an acute allergic reaction to which the body has become hypersensitive.
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|
|
Antibiotics such as the penicillins inhibit formation of the cell wall individing bacteria. Bacteria die as a result.Why don’t human cells die? |
Human cells do NOT have a cell wall |
|
|
Talk about features of cephalosporins |
• isolated from sea fungus near a sewerage outlet • active component is 7-aminocephalosporanic acid • 1st, 2nd, 3rd, & 4th generations • beta-lactam ring essential to activity of drug |
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|
What are the pharmacodynamics of cephalosporins? |
• bactericidal • rapidly dividing bacteria are affected most • emergence of resistant strains (so not better than penicillins) eg) MRSA |
|
|
What are the pharmacokinetics of cephalosporins? |
• antibiotic dependent • few oral formulations; mainly IM or IV injections • renal excretion |
|
|
What are the indications for cephalosporins? |
• prophylaxis for bowel and gynaecological surgery - infections esp. bowel or gynocological |
|
|
What are some of the ADRs for cephalosporins? |
- diarrhoea - abdominal cramps/distress - rash - oedema - allergicreactions |
|
|
What drugs interact with cephalosporins? |
• anticoagulants • NSAIDs |
|
|
What are contraindications of cephalosporins? |
Bacterial protein synthesis inhibitors |
|
|
What are some examples of bacterial protein synthesis inhibitors? |
• macrolides eg) erythromycin • lincosamides eg) lincomycin • aminoglycosides eg) gentamicin • chloramphenicol • oxazolidinones eg) linezolid • stretogramins eg) quinupristin with dalfopristin • tetracyclines eg) doxycycline |
|
|
What is erythromycin? |
Antibiotic with many-membered lactone ring with one or more sugar molecules |
|
|
What are the pharmacodynamics of erythromycin? |
DOES IT ALL! WOW! • bacteriostatic • bactericidal at high concentrations |
|
|
What are the pharmacokinetics of erythromycin? |
• inhibit hepatic CYP3A4 thus inhibiting the metabolism of other drugs • billary excretion |
|
|
What are the pharmacological effects and indications for erythromycin? |
• gram +ve bacteria and some gram –ve bacteria involved : a cocktail • various infections when penicillins are contraindicated |
|
|
What are some ADRs of erythromycin? |
- abdominal cramps - diarrhoea - nausea - vomiting |
|
|
What are some drug interactions of erythromycin? |
• benzodiazepines • digoxin (cardiac stimulant from foxglove) • warfarin |
|
|
What is antibiotic resistance? |
• microorganism is resistant to the antibiotic • intrinsic resistance • acquired resistance |
|
|
Define intrinsic resistance |
- The innate ability of a bacterial species toresist activity of a particular antimicrobial agent through itsinherent structural or functional characteristics - Allowstolerance of a particular drug or antimicrobial class. This canalso be called “insensitivity” |
|
|
Define acquired resistance |
Acquired resistance is said to occur when a particular microorganismobtains the ability to resist the activity of a particularantimicrobial agent to which it was previously susceptible. This canresult from the mutation of genes involved in normal physiologicalprocesses and cellular structures, from the acquisition of foreignresistance genes or from a combination of these twomechanisms. |
|
|
What causes antibiotic resistance? |
over-use and over-prescription of antibiotics |
|
|
What are the mechanisms of antibiotic resistance? |
• barrier to entry • efflux pump • formation of biofilm • enzymatic inactivation eg) β-lactamases • target site modification • increased synthesis of target • target adaption |
|
|
What is the efflux pump? |
Proteinaceous transporters localized in the cytoplasmic membrane of all kinds of cells. They are active transporters, meaning that they require a source of chemical energy to perform their function. |
|
|
How do efflux pumps relate to anti biotic resistance? |
Expression of several efflux pumps in a given bacterial species may lead to a broad spectrum of resistance when considering the shared substrates of some multi-drug efflux pumps, where one efflux pump may confer resistance to a wide range of antimicrobials |
|
|
Why do we eat? |
- Meet metabolic needs - Maintain homeostasis - Important in tissue repair |
|
|
What increased metabolic rate? |
• stress • sympatheticstimulation • fever • Being male (muscle &testosterone) |
|
|
What decreases metabolic rate? |
• ageing • end-stage illness • sleep |
|
|
What happens if metabolism doesn't happen? |
Our cells have no fuel > starve > death |
|
|
What are the two main aspects of metabolism? |
Anabolism and Catabolism |
|
|
What does trauma do to metabolism? |
It is a form of trauma so body starts catabolising things to get ready to rebuilt the body |
|
|
What can stress the body and metabolism further? |
- Hypo/hyper volemia - sepsis - fever - Medications |
|
|
What are the benefits from adequate nutrition in reards to surery? |
- Improved wound healing - improved immune response - Reduce infection - Reduce hospital stay - Lessen mortality/morbidity |
|
|
What percentage of people are admitted to hospital with poor nutrition? |
30-40% of patients |
|
|
What causes lack of appetite? |
- N / V - Taste alterations and aversions - Pain - Depression - Drugs - Biochemical imbalances - Lack of exercise/Mobility - Constipation |
|
|
What is the body's response to inadequate nutrition? |
- Mobilise stored fat, protein & glycogen - From Adipose tissue and skeletal muscle Leads to protein-calorie malnutrition |
|
|
Who tailors diet to the patient? |
Dietitians |
|
|
What should you consider for your patient's diet? |
- Food allergies - Lifestyle (Vegan) - What type of surgery they had - Elderly (Dentures?) - Hiding veggies etc in food for children/big children |
|
|
What influences taste? |
- Sense of smell > Airborne molecules reach olfactory receptors (Cranial nerve I) > Dissolves into mucous ***Head injury can change it - Bad smells (hospital, flowers, vomit) - Patient age (old people can't taste as well, needs flavour) |
|
|
What affects food itself that decides if we want to eat it or not? |
- Flavour - Texture - Appearance - Temperature |
|
|
What is emotional eating? |
Eating food for comfort's sake - Simple and familiar - warm and filling - basically speaking (sweets) (chocolate) |
|
|
What else effects what your pt is allowed to eat culturally? |
- Status - Family tradition - Religion - Cultural cuisine - Fasting (Eg/ Ramadan) |
|
|
What type of process is healing? |
Anabolic |
|
|
What are the two types of nutrients needed for wound healing? |
Macronutrients Micronutrients Eg/ Vitamin C and Zinc |
|
|
Why do we need vitamin C? |
- Helps make collagen - Promotes for WBC to do their killing |
|
|
What is the most important macro-nutrient in healing? |
Protein |
|
|
What does protein do for our body? |
- Cell-immediated immunity - Making fibroblasts - Makes new blood vessels - Helps make components of the nervous system - Helps maintain out blood pressure - Maintains acid-base balance - Keeps fluid balance in check - Energy source (last resort though) |
|
|
What gas do we lose through an open would that is a part of protein? |
Nitrogen |
|
|
What is an example of a simple carbohydrate? |
- Glucose - Energy for cells including WBC > helps with healing and preventing infection |
|
|
Why do we need to eat fats? |
- To maintain our phospholipid bilayer
- To produce certain hormones and prostaglandinds >regulates cell function |
|
|
Why do we need vitamins? |
- Multiple fuctions - Many help with making/working with enzymes - Collagen |
|
|
Why do we need minerals?? |
- Iron transports oxygen - Immune cell function (Iron and zinc) - Collagen - Cell proliferation |
|
|
Name a metabolic disorder |
Diabetes mellitus - Increased glucose release - Diminished uptake of muscle and fat >corticosteroids (MORE GLUCOSE = DANGER) >catecholamines (like adreneline) |
|
|
What does mobility do to nutrition? |
- Loss of calcium in bone (don't use it = lose it) - Loss of nitrogen (muscle atrophy - Constipation |
|
|
What is a problem regarding the elderly and nutrition? |
- Appetite - Dentures & Oral problems - Diminished taste/ sense of smell - Dementia patients are less likely to eat > Improving their nutrition in hospital can improve physical and mental status - Cannot metabolise as well > Harder to digest and use protein - Diet must suits the person >Be individualised - More likely to be depressed which increases dementia risk with lowers eating ... cyclic and when you eat less you are more likely to be depressed.... what a mess |
|
|
Define haemostasis |
prevention of blood loss from damaged vessels |
|
|
What are the Haemostatic mechanisms? |
1) blood vessel constriction 2) platelet plug formation 3) blood coagulation 4) clot retraction |
|
|
Why does blood vessel constriction occur? |
reduces flow of blood from ruptured vessel |
|
|
Why does Platelet plug formation occur? |
To create a temporary seal • platelets adhere to underlying collagen • platelets release chemicals that attract more platelets eg) thromboxane A2 (TXA2), adenosine diphosphate (ADP) • platelet plug needs reinforcement |
|
|
How does blood coagulation work? |
Vessel injury & constriction |
|
|
What is the first Factor activated in the intrinsic pathway? |
XII |
|
|
What converts Fibrinogen to fibrin? |
Thrombin |
|
|
What is the first Factor activated in the common pathway? |
X |
|
|
What is the first Factor activated in the Extrinsic pathway? |
VII |
|
|
What Factor stabilizes Fibrin? |
XIII |
|
|
What is the SIMPLE version of the clotting cascade? |
Prothrombin > Prothrombin activator > Thrombin . Thrombin converts fibrinogen to fibrin Thrombin also converts factor XIII into factor XIIIa which then makes the fibrin stable |
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What ion do you need to help activate pathways of the clotting cascade? |
Calcium
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What is clot retraction? |
Clot contracts and expresses fluid (serum) |
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What is the easy way to describe the clotting cascase and how it causes haemostasis? |
Its a plug and stops the blood from leaving the vessel |
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Define Fibrinolysis |
Normal physiological process dissolves clot after formation |
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What are the mechanisms of fibrinolysis? |
plasminogen is activated by : |
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What are our anti-coagulation systems? |
• limit clot formation Example • antithrombin III • inactivates thrombin |
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Define thrombosis |
IS PATHOLOGICAL! NOT NORMAL Definition • process of forming a thrombus |
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What is a thrombus? |
BLOOD VESSEL IS NOT BROKEN BUT A CLOT FORMED! |
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What is the Aetiology of forming a thrombus? |
1) endothelial injury
2) stasis or turbulence (abnormal blood flow) 3) blood hypercoagulability VIRCHOW's TRIAD |
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What are the three corners of the Virchow Triad? |
- Endothelial injury - Abnormal flow (status or turbulence) |
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What is the pathogenesis of a thrombosis caused by endothelial injury? |
Causes : > creating endothelial dysfunction > Inflammation > coagulation cascade triggered > thrombus formed |
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What is the pathogenesis of a thrombosis caused by stasis or turbulence (abnormal blood flow) ? |
• blood normally flows in straight lines • ATH plaques, aneurysms, MI, AF and hyperviscosity syndromes & hyperglycaemia > creating local pockets of stasis and turbulence > injuring endothelial cells > coagulation cascade triggered |
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What cells are the only cells capillaries are made up of? |
Endothelial cells |
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What is lamina flow? |
Flow in a straight line (normal for our blood) |
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What is the pathogenesis of a thrombosis caused bypercoaguability? What is the causes? |
Primary: Genetic mutations eg) mutations in genes for clotting factors > Factor V Leiden Thrombophillia Secondary: acquired High risk eg) prolonged immobilisation, surgery, fractures, burns, cancer Low risk eg) contraceptive pill use, smoking |
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What is an aneurysm? |
A distended blood vessel prone to rupturing, looks like a balloon |
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Where are key sites for arterial thrombi? |
coronary, cerebral or femoral arteries |
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What can a thrombus become? |
An emboli |
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Define an emboli |
A travelling clot |
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What are the key sites for venous thrombi? |
superficial veins or deep veins of leg |
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What is the clinical significance of superficial venous thrombi? |
• Superficial vein thrombosis
• congestion, swelling, pain, tenderness • rarely embolize |
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What is the clinical significance of DEEP venous thrombi? aka DVT? |
• possible pain and oedema • 50% asymptomatic • pulmonary embolus (likely to get stuck in the lungs |
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What is a Mural thrombus? |
Thrombus in contact with the endocardial lining of the cardiac chamber or a large blood vessel |
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What happens if you survive a thrombi? What 4 things may happen? |
1) grow larger 2) embolise 3) dissolve 4) scar tissue |
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What two main groups of drugs affect blood coagulation? |
Drugs used for prevention & treatment of thrombosis Drugs that control rapid blood loss |
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What drugs used for prevention & treatment of thrombosis? |
1) anticoagulant drugs 2) thrombolytic drugs 3) anti-platelet drugs 4) direct thrombin inhibitors 5) direct factor Xa inhibitors |
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What drugs are used for control of rapid blood loss? |
1) haemostatic drugs 2) antifibrinolytic drugs |
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How do anticoagulant drugs work? |
Prophylactically |
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What are the two main groups of anticoagulant drugs? |
1) parenteral anticoagulant drugs 2) oral anticoagulant drugs |
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Give examples of parenteral anticoagulant drugs |
eg) heparin (unfractioned) eg) low molecular weight heparin (LMWH) |
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Give an example of a oral anticoagulant drug |
warfarin |
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What is the pharmacodynamic of UFH? |
• two mechanisms 1) to inhibit thrombin: • heparin binds to antithrombin III (ATIII) • heparin-ATIII complex inactivates thrombin > no conversion of fibrinogen to fibrin > no stable fibrin > inhibit platelet aggregation • heparin binds to antithrombin III (ATIII) > inhibiting factor Xa > inhibiting intrinsic and extrinsic pathways |
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What is ATIII? |
Antithrombin III |
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What are the Pharmacokinetics of UFH? |
Parenteral administration |
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What are the Pharmacological effects of UFH? |
• anti-coagulant
• no fibrinolytic activity |
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What are indications for UFH? |
• prevention of venous thromboembolism • prevent blood clot formation during surgery, blood transfusions, disseminated intravascular congestion (DIC), (lots of little clots in small vessels) |
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What is haemodialysis? |
Kidney dialysis
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What are some ADRs of UFH? |
- Haemorrhage - Signs of overdose |
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What are examples of LMWHs? |
dalteparin enoxaparin (clexane) |
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What is the main difference between UFH and LMWH's mode of action? |
LMWH do NOT inactivate Heparin, only Factor Xa |
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What is the pharmacodynamics of LMWH? |
• LMWHs bind to ATIII > inactivate factor Xa > inhibiting intrinsic and extrinsic pathways |
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What test does LMWH not show up on? |
APTT |
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What do both types of heparin bind to to exert an effect? |
ATIII inactivating Xa
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Why is LMWH safer and easier to administer? |
Unlike UFH it can be given via subcut
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What is an indication for giving LMWH instead of UFH? |
Thromboembolism associated with pregnancy • prevention of venous thromboembolism • prevent blood clot formation during surgery, blood transfusions,disseminated intravascular congestion (DIC), haemodialysis |
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What does warfarin stand for? |
Wisconsin Alumni Research Foundation and Coumarin |
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What family is warfarin from? |
courmarin family |
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What are the pharmacodynamics of Warfarin? |
• vitamin K is essential for hepatic synthesis of prothrombin (factor II)and factors VII, IX and X CAN'T USE UP K TO MAKE FACTORS |
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What is essential for the liver to make clotting factors II, VII, IX and X? |
Vitamin K |
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What are the pharmacokinetics of Warfarin? |
Absorption • oral administration Distribution • highly protein bound |
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What type of drug is Warfarin? |
• Oral anti-coagulant • prevents extension of formed clots |
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What are the indications for Warfarin? |
• prophylaxis & treatment of DVT & pulmonary thromboembolism • prophylaxis of thromboembolism associated with AF, MI or prosthetic heart valves |
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What are the ADRs for Warfarin? |
• bleeding (increased risk if over 70 years, stroke, DIs, GI bleeding,liver and kidney disease) • alopecia, nausea, vomiting |
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What is alopecia? |
Hair loss |
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Drug interactions for Warfarin? |
A HEAP!!! |
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Define Thrombolytic drugs (aka fibrinolytic drugs)
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• dissolve existing clots • main drugs include: 1) recombinant tissue plasminogen-activator (rt-PA) 2) streptokinase |
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What are some examples of rt-PA drugs? |
alteplase |
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What are the pharmacodynamics of rt-PA drugs? |
Plasminogen is activated by rt-PA to make plasmin to dissolve the fibrin |
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What are the contraindications of rt-PA drugs? |
Any bleeding conditions eg/ Hemorrhages, strokes |
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What are the indications for rt-PA drugs? |
Lysis of thrombi eg/ In acute MI or PE |
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What are the ADRs for rt-PA? |
Stroke Arrhythmia Cardiac arrest P re-E |
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What are the drug interactions for rt-PA? |
Anti coagulants Vitamin K antagonists |
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What are anti-platelet drugs? |
• used in treatment of arterial thrombosis • main drugs include:1) aspirin • decreases PG and TXA2 synthesis |
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What is the main anti-platelet drug used? |
Aspirin
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How does aspirin work? |
• decreases PG and TXA2 synthesis |
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How does TXA2 work and what is it? |
Thromboxane A2 Call in more platelets to clump together |
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How does clopidogrel (Plavix) work? |
• inhibits ADP-induced platelet aggregation |
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What are some examples of anti platelet drugs? |
1) aspirin • decreases PG and TXA2 synthesis 2) clopidogrel (Plavix®) • inhibits ADP-induced platelet aggregation 3) dipyridamole 4) ticlodipine 5) abciximab |
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What are some examples of direct factor Xa inhibitors? |
Rivaroxaban |
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How does RivaroXaban work? |
• reversible dose-dependent competitive inhibitor of factor Xa |
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What is an example of a hirudin analogue? |
Medicinal leeches |
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Where is hirudin from? |
isolated from the leech pharyngeal glands |
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What are some analogues/recombinant forms of hirudin? |
eg) bivalirudin, lepirudin |
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Define recombinant |
Formed by recombining things |
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Define analogue |
Something that is comparable to another |
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What is an example of a direct thrombin inhibitor starting with D? |
Dabigatran etexilate • inhibits free and clot-bound thrombin |
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What are some drugs that control rapid blood loss? |
1) Haemostatic drugs 2) Antifibrinolytic drugs |
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How do haemostatic drugs work and what do they work on? |
• hasten clot formation and reduce blood loss
Works on : • factors VII, VIII, IX • protamine • vitamin K |
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What do antifibrinolytic drugs do? |
• reduce fibrinolytic activity |
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What is an example of an antifibrinolytic drug? |
tranexamic acid
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How does tranexamic acid work? |
competitive inhibition of plasminogen activator |
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What is an indication for transexamic acid? |
• heavy menstrual bleeding - dental surgery for individuals with haemophilia |
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What are the three tests for testing coagulation? |
APTT |
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Define APTT |
• measures overall activity of intrinsic coagulation pathway |
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Define PT |
• reported as the number of seconds blood takes to clot when mixed with a thromboplastic reagent • measures effectiveness of warfarin |
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Define INR |
• measures overall activity of extrinsic coagulation pathway • conversion unit that takes into account the different sensitivities of thromboplastin reagents |
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What is the main difference between APTT and PT? |
PT is JUST how long it takes to clot |
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What should be included in pre-operative /interview? By which professionals? |
- Nursing assessment - Surgeon assessment - Anaesthetic assessment - Diagnostic testing - Allied health review e.g.pharmacist, physiotherapist,dietician, stoma therapist etc. |
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On top of vitals, allergies, medications... what else should be included in a pre-op nursing assessment? |
Diagnostic results > ECT/CT/CXR/CT > Other drugs Psychological assessment > Patient understanding of condition & surgery > HOW STRESSED THEY ARE > Spiritual/cultural beliefs Social support > Family or other support/involvement >Nutritional status |
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What are some pt risk assessment tools? |
- Falls risk assessment ◦ E.g. Hendrich II Fall Risk Model ◦ Ontario Falls Risk ◦ E.g. Braden Scale, Waterlow - Nutrition risk assessment ◦ E.g. Malnutrition screening tool (MST) |
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What must nurses recognize for their pt as part of their assessments? |
Identify risk factors ◦ Using risk assessment tools > Analyzing diagnostic data ◦ Eg. Urinalysis, ECG, etc > Develop nursing diagnoses ◦ Potential problems ◦ Actual problems |
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What are some examples of pre-operative diagnostic tests? |
- ECG - CXR - Full blood count/examination (FBC or FBE) - Liver function (LFT) > can they clot properly? - Renal function > urea, electrolytes, creatinine(UEC) + Ca2+, Mg2+, HPO42- (Phosphate) - Coagulation studies - Cross match, group and hold - Urinalysis |
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What are some peri-operative risk factors? |
◦ Age ◦ Nutritional status ◦ Fluid and electrolyte balance ◦ General health/co-morbidities > Eg. Neurological, Cardiovascular, Respiratory,Gastrointestinal, Hepatic, Endocrine, Renal,Integumentary/ Musculoskeletal conditions ◦ Medications ◦ Lifestyle choices ◦ Medical/surgical history ◦ Allergies ◦ Anaesthesia ◦ Procedure type |
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What is HPO42- and why is it tested? |
Phosphorus High levels indicate > Hypoparathyroidism > Kidney failure > Liver disease > Too much vitamin D > Too much phosphate in your diet > Use of certain medications such as phosphate-containing laxatives Low levels indicate : > Hypercalcemia > Hyperparathyroidism > Too little dietary intake of phosphate > Very poor nutrition > Too little vitamin D, resulting in rickets (childhood) or osteomalacia (adult) |
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What is osteomalacia? |
Softening of bones |
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What are some surgical risk factors for the older adult? |
- Risk & severity of complications dueto altered physiological, cognitive &psychosocial responses to surgery - ? Chronic illness; co-morbidities;medications - Lowered ability to cope with stress - Lowered tolerance of general anaesthesia &medications - Lowered quantity of muscle tissue can lead to hypothermia and lowerdrug metabolism - Delayed wound healing - May be malnourished |
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Why is nutritional status impotant in regards to surgery? |
Optimal nutrition > Promotes healing > Resist infection & surgicalcomplications > Nitrogen balance Assessment - Diet, obesity, undernutrition, malnutrition,weight loss, BMI, waistcircumference. - Conditions which increase surgicalrisk inc: > Malnutrition > Obesity |
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What are some post-operative complications related to malnutrition? |
◦ Poor wound healing > due to increased metabolic demands of tissues ◦ Infections ◦ Fluid overload > Low blood proteins = Oedema ◦ Organ failure - Reserves of nitrogen not sufficient to allow body torespond to physical & psychological stresses ofsurgery. |
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What are the surgical risks associated with obesity? |
- increased risk & severity ofcomplications due to stress onmultiple systems - Lower access to surgical site intra &post-op - Stress on suture lines - Anaesthetic risk - Positioning & mobilisation - May need specialised equipment formobilisation - Wound dehiscence, infection & delayed healing - Incisional herniation (pressure) - Slower recovery from anaesthetic - Pulmonary complications - Thrombosis due to decreased mobility - Higher chance of Diabetes mellitus (syndrome X) - Cardiac complications - Gastro-oesophageal reflux disease (GORD) |
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Why would obese pts have issues with Wound dehiscence, infection & delayed healing? |
◦ Adipose tissue less vascular > increased susceptibility toinfection > decontamination > harder to keeping clean ◦ May have diabetes ◦ May be malnourished |
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Why would an obese pt recover slower from anaesthesia? |
◦ Adipose tissue stores inhalation gases, > some drugs lower mobility (drowsiness) = DVT ◦ May require higher dosage of medications |
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What are some surgical pulmonary complications regarding obesity? |
- Atelectasis - Pneumonia - Hypoxia;airway obstruction due to difficulty withpositioning, repositioning, mobilisation, shallowbreathing when supine. - Sleep apnoea |
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Define pneumonia |
lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid. Inflammation may affect both lungs ( double pneumonia ) or only one ( single pneumonia ). |
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What are some surgical cardiovascular complications regarding obesity? |
◦ Hypertension due to increased length of bloodvessels due to excess weight ◦ High cholesterol resulting in atherosclerosis |
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What are some risks factors for electrolyte imbalance and hypo/hypervolaemia? |
- vomiting - diarrhoea - renal function impairment - intake, output, - serumelectrolytes - medications (diuretics, laxatives), diet. |
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What can happen in cases of high levels of dehydration and or/type ofelectrolyte imbalance? |
- Acute pulmonary oedema (APO) - Cardiac arrhythmias - Acute renal failure |
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Why is Na+ an important electrolyte and what is an acceptable range? |
(135-145mmol/L) - nerve transmission - muscle contraction - maintains normalfluid concentration and volume of ECF |
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Why is Cl- an important electrolyte and what is an acceptable range? |
(95-107mmol/L) - acid/base balance - nerve transmission |
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Why is K+ an important electrolyte and what is an acceptable range? |
(3.5-5mmol/L)
- nerve transmission - muscle contraction - normal heart rhythms - concentration of ICF |
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Why is Ca2+ an important electrolyte and what is an acceptable range? |
(2.1-2.6mmol/L) - nerve transmission - muscle contraction - strong bones & teeth - bloodclotting - enzyme reactions |
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Why is Mg2+ an important electrolyte and what is an acceptable range?
|
(0.75-1.0mmol/L)
- enzyme reactions - cardiac & respiratory function |
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Why is HPO4 2- an important electrolyte and what is an acceptable range? |
(0.8-1.4mmol/L) affects Ca2+ levels |
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How do we assess CVS risks? |
- Look for pre-existing disease > baseline vitals > baselinebloods > currentmedications > concordancewith treatment - Monitor cardiac functionduring intra and postoperative periods - Understand normal ECGpattern |
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What are some CVS risk factors? |
History of: - Hypertension - Ischaemic heart disease(IHD) - Valvedisease/prostheticvalves - Myocardial infarction - Left or right ventricularfailure (LVF or RVF) - Congestive cardiacfailure (CCF) |
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What are some CVS complications? |
- Arrhythmias - Deep vein thrombosis(DVT) > increased risk of PE - Cardiac failure - Hypotension > lowcardiac output -> renalfailure - Hypertension > Increased risk ofintra and post-opbleeding/stroke |
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How do anesthetics impair lung function? |
- Incomplete lungexpansion due to : ◦ Hypoventilation ◦ Patient position(supine, prone) ◦ Dependentventilation ◦ Affected by length of surgery |
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What are some conditions that can lead to hypoxia in theintra/post-op periods? |
- Bronchitis
> Leads to airwayinflammation > secretions - Asthma > bronchoconstriction - Laryngospasm > uncontrolled spasm/constriction of thelaryngeal vocal cords dueto anaesthetic agents - Atelectasis - Pneumonia - Chronic obstructivepulmonary disease(COPD) |
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What are the risks for a pt's gastrointestinal system in regards to surgery? |
Anaesthetics & opioids ◦ Delay gastric emptying ◦ Decreased peristalsis -> paralyticileus Haemorrhage & stress ◦ Blood flow directed tobrain, heart and lungs &away from GIT ◦ decreased intestinal blood flow > intestinal ischaemia - Gastric ulceration due tostress - Abdominal distension - Constipation |
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How do we do risk assessment of the liver? |
- Assess for liver disease e.g.hepatitis or alcoholic liverdisease > Can lead to cirrhosis, nonalcoholicfatty liver disease,clotting disorders, low serumprotein - check liver function results |
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What are potential surgical complications related to the liver? |
- Acute liver failure - Increased risk of haemorrhage - Increased risk of infections/sepsis - Decreased wound healing |
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What are some neurological risks associated with anaesthetics and opioids? |
- Post-operativedelirium > agitation,confusion,restlessness,disorientation - Higher risk ifconcurrentdrug/alcohol use orother neurologicaldisorders present |
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What needs to be included in a nuerological risk assessment? |
Cognitive function - History e.g. stroke, dementia Parkinson's disease drug use e.g. marijuana, diazepam,alcohol use, anxiety, depression, electrolytes levels. - Neurovascular function e.g. loss of sensation, |
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Why would we test a pt's cognitive function? |
Required if preparing for surgery - Required careful assessment of current function Includes - Orientation - Family involvement |
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How do we assess risks regarding the renal system? |
- Fluid/electrolyte balance - Renal function via serumcreatinine & urea levels, - Urinary problems ◦ Enlarged prostate (BPH) ◦ Incontinence ◦ Urinary tract infection(UTI) |
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What does decreased renal function do regarding drugs? |
Alteredresponse to standard drugdoses, variable elimination > Toxicity |
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What does a risk assessment of the integumentary system include? |
- Age - Co-morbidities > diabetes > obesity, > corticosteroid > mobility > nutritionalstatus > cognitivestatus > surgery type |
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What are potential issues when the integumentary system is impaired? |
- Poor wound healing - Tissue breakdown |
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What are some risk factors related to the endocrine system? |
- T2DM - Corticosteroid use - Thyroid dysfunction |
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Why is T2DM an issue in regards to surgery? |
◦ Fasting/anaesthetics/vomiting ◦ Stress People with diabetes have increased risk of : - cardiovascular disease - poor wound healing & infectiondue to decreased mobilisation ofinflammatory cells & impairedphagocytosis - abnormal sensation - diabetic nephropathy |
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What can corticosteroid use cause? |
adrenal insufficiency |
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What can thyroid dysfunction cause? |
- Thyrotoxicosis > respiratoryfailure > inability tomaintain bodytemperature > inability tometabolise drugs |
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|
What are some pharmacokinetic related medication risks in regards to surgery? |
Liberation
> the process of drug release from the dosage form. Drugs can get 'knocked off' and freed at the wrong time Change to ADME : absorption,distribution, metabolism, excretion of drugs |
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What are some pharmacodynamic related medication risks in regards to surgery? |
- Anaesthetics can interact with medications and cause : > respiratory difficulties > hypotension > shock ◦ Morphine/anticholinergics &longer acting inhalation anaesthetics > Decrease gastric emptying > Decrease oral drug absorption |
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What DDI (drug-drug interaction)s can anaesthetics have? |
- Decreased metabolism of some drugs e.g. propanolol,verapamil, lignocaine, fentanyl - Affect protein binding > Increased drug in bloodstream > Lower drug clearance due to alteration of enzymesin liver and hepatic blood flow |
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What happens if a pt has anticoagulants & non steroidal anti-inflammatory drugs before surgery? |
Increase chance of intra & postoperative bleeding |
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How do anaesthesic drugs interact with antihypertensives? |
- May increase hypotensive effects of anasthesia |
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How do anaesthesic drugs interact with herbal supplements? |
Some may prolong effects of anaesthesia. Others mayincrease the risk of bleeding or alter blood pressure e.g. St John’s wort can lead to hypotension & delayedrecovery from anaesthesia |
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What is a surgical risk of corticosteroids? |
- Fragile skin - skin breakdown - Risk of infection |
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|
What are some risks of excessive alcohol intake? |
- Malnourishment - Withdrawal (delirium tremens) - Require more anaesthetic - Effects of damaged liver |
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|
What are some risks associated with smoking? |
- Increased mucous secretions
- Decreased expectoration"Spitting up" - Additional respiratory support usually required- Increased time to recover to ‘normal’ resp. function - Increased risk of respiratory complications |
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|
What are some non-drug allergies? |
Food chemicals tapes pollen latex |
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|
What are some potential ADR risks due to allergies? |
◦ Contact dermatitis ◦ Hives (urticaria) ◦ Respiratory reactions – stridor, dyspnoea ◦ Swelling - mouth, tongue ◦ Complete anaphylaxis |
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What does increased length of anaesthsia or procedure time mean? |
increased risk of complications
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What do more invasive procedures have a higher risk of? |
◦ Haemorrhage ◦ Atelectasi & chest infection ◦ Wound infection ◦ DVT ◦ Paralytic ileus ◦ Problems with thermoregulation |
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|
What is the ASA classification system? |
AMERICAN ANAESTHESIOLOGISTSASSOCIATION CLASSIFICATION SYSTEM To help assess which anaesthetic to use |
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|
What is ASA PS1? |
Normal healthy pt |
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What is ASA PS2? |
Pt with mild systemic disease |
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What is ASA PS3? |
Pt with severe disease |
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What is ASA PS4? |
Pt with severe disease that constantly threatens their life |
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What is ASA PS5? |
'Moribund' pts not expected to survive a surgical procedure |
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|
Define Moribund |
At the point of death/ In terminal decline |
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What is ASA PS6? |
A pt declared brain dead |
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|
What is the mallampati visual score? |
Used to check ease ofintubation (Breathing tube) Class I-IV |
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What is Class I on the mallampati visual score? |
soft palate, uvula,fauces, pillars visible. |
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What is Class II on the mallampati visual score? |
soft palate, uvula,fauces visible. |
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What is Class III on the mallampati visual score? |
soft palate, baseof uvula visible. |
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What is Class VI on the mallampati visual score? |
hard palate onlyvisible |
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What is intubation? |
Placement of tubing in to the trachea to assist in getting oxygen to the lungs Usually an endotrachial tube |
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What is the anatomy involved in judging the mallampati visual score? |
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What are the two main types of surgical thermoregulatory risks? |
- Hypothermia in recovery phase due to anaesthetics & heat loss - Hyperthermia (may indicate infection) |
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|
What is malignant hyperthermia? |
Genetic disorder Anaesthetics lead to influx of Ca2+ into muscles > results inuncontrolled muscle contractions => hyperthermia (over 41c) |
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|
What CNS complications can hypothermia cause? |
Cardiac Arrythmias => slows cardiac conduction |
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|
What CNS complications can hyperthermia cause? |
MI |
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|
What are nosocomial infections? |
infections are acquired in hospitals and other healthcare facilities. |
|
|
Define myopia |
Short sightedness |
|
|
What does the thyroid affect? |
- Energy consumption > metabolism - Sympathetic stimulation > fight or flight responses - RBC formation affects –> oxygen delivery - Stimulate activity in other endocrine tissues |
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|
What hormones does the thyroid pruduce? |
thyroxine (t4) & triidothyronine (t3)
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|
What is triiodothyronine? |
aka t3 |
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|
What is thyroxine? |
aka t4 the main hormone produced by the thyroid gland, acting to increase metabolic rate and so regulating growth and development. |
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|
Define hypothyroidism |
Abnormally low activity of the thyroid gland
> affects levels of growth & activity in the thyroid Does not produce enough thyroid hormones |
|
|
What can cause hypothyroidism? |
◦ Due to loss of thyroid tissue
◦ Due to decreased pituitary release of TSH |
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|
What is TSH? |
thyroid-stimulating hormone |
|
|
What can result from hypothyroidism? |
- Decreased metabolism - Decreased body temperature - Decreased myocardial function > bradycardia - Decreased spontaneous ventilation - abnormal baroreceptor function - decreased plasma volume > anaemia - Increase in adrenal insufficiency - constipation |
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|
What is spontaneous ventilation? |
normal, unassisted breathing |
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|
What are potential post-op complications of hypothyroidism? |
- Hypothermia - Prolonged anaesthesia - CVS and RR depression - Less ability to cope with surgery |
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|
What is anaemia? |
a condition in which there is a deficiency of red cells or of haemoglobin in the blood, resulting in pallor and weariness.
Can also be caused by B12 or iron deficiancy |
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|
What are acceptable ranges for Hb? |
◦ Women 12-14 ◦ Men 14-16 |
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|
What are some types of anaemia? |
◦ Iron deficiency anaemia - lack of iron in diet,blood loss ◦ Pernicious anaemia - lack of intrinsic factor > due todecreased B12 absorption or lack of B12 in diet |
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|
What are some post-op complications of anaemia? |
- Hypoxaemia
- Poor healing - Increased recovery time |
|
|
What values means someone is suffering from HTN? |
◦ Systolic > 140 ◦ Diastolic > 90 (WHO definition) |
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|
What is HTN associated with? |
Associated with arrhythmias & myocardialischaemia
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|
What are the perioperative risks associated with HTN? |
◦ Hypotension post induction of anaesthesia ◦ Sympathetic response to surgical stress e.g. intubation,incisions can increase BP ◦ Extra sympathetic response post surgery e.g. bladder distension increases pain which further increases BP |
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What are some post-op complications associated with HTN? |
- Bleeding - Cerebrovascular haemorrhage - Myocardial ischaemia/infarction - High mortality rate. |
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What are some statistics of brain cancer? |
- In 2010, there were 1,680 new cases of brain cancer inAustralia - In 2014, about 1,785 Australians were expected to bediagnosed with brain cancer. - In 2020, an estimated 2,055 Australians are expected tobe diagnosed with brain cancer. - In 2011, there were 1,272 deaths from brain canceraccounting for 2.9 per cent of all cancer deaths inAustralia. - The risk of developing brain cancer increases with age |
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What are some characteristics of brain tumours? |
- Can occur in any part of the brain or spinal cord - May be PRIMARY or SECONDARY - More than half are malignant - Result in increased ICP > Due to obstruction of the flow of CSF > Space occupying Surgical therapy is the preferred treatmentTreatment goals aim to: ◦ Identify the tumour type and location ◦ Remove or decrease tumour mass ◦ Prevent or manage increased ICP |
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Why do brain tumours increase ICP? |
> Due to obstruction of the flow of CSF > Haemorrhage around or in tumour > Space occupying |
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What is ICP? |
Intercranial Pressure
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What is CSF |
Cerebro-spinal fluid |
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What are the treatment goals for surgery of a brain tumour? |
◦ Identify the tumour type and location
◦ Remove or decrease tumour mass ◦ Prevent or manage increased ICP |
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What is the Monro-Kellie Hypothesis? |
The pressure-volume relationship between: - CSF volume |
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What is CPP? |
Cerebral perfusion pressure |
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The brain is enclosed in rigid skull with 3 volumes. What are the 3 volumes? |
◦ Brain tissue (80%)
Affected by > Brain tumours > Haemorrhage/cerebral blood clots > Cerebral oedema ◦ Blood in blood vessels (10%) > 15-20% cardiac output goes directly to brain ◦ Cerebrospinal fluid (10%) - Approx: 150ml in adults |
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What is the normal range for CPP? |
50-150mmHg If ICP 0-10mmHg perfusion maintained if MAP >70mmHg |
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How do you calculate MAP?
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Dia BP - (Sys - Dia pessure) = MAP |
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Why is it so hard to keep CPP even when they have a blood tumour? Why is the issue cyclic? |
Brain tumour/blood Or Hydrocephalus > Decreased cerebral infusion |
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What actions can increase ICP? |
◦ Coughing ◦ Valsalva manoeuvre ◦ Vomiting ◦ ICP > 15mmHg = intracranial hypertension |
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How do blood gases affect ICP? What causes the changes? |
Hypercapnia (PaCO2 > 45mmHg) or Hypoxia (PaO2< 50mmHg) Causes vasodilation of cerebral bloodvessels > fluid leaks from blood vessels into braintissue => cerebral oedema & increased ICP |
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Define Hypercapnia |
Is a condition of abnormally elevated carbon dioxide (CO2) levels in the blood. |
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What are the aims of a craniotomy? |
◦ To remove a tumour ◦ Evacuate a blood clot ◦ Control haemorrhage ◦ Relieve increased ICP ◦ While preserving neurological function |
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What is the craniotomy surgical procedur?e |
◦ Section of skull removed to create a bony flap ◦ Repositioned after surgery ◦ Different approaches may be used |
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What are some complications of brain surgery? |
- Cerebral oedema - Haemorrhage - Infection - Post-operative seizures - Neurological deficits ◦ swallowing, sensation, speech disturbances,personality, visual disturbances, loss of cognitivefunction, ability to do calculations, memorydeficits - Permanent vegetative state |
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What is it called when a brain herniates? |
Coning |
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What are the 3 layers of the meninges |
Dura mater Arachnoid mater Pia mater |
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What are some Neuropsychological complications of a surgery? |
Pain Fever Delirium Hypothermia Cerebral Oedema |
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What are some reasons for performing a craniotomy?
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To remove: - Get a tissue sample or biopsy - Remove a blood clot/haemotoma - Excess CSF - Pus from an infection / Drain abscess - To relieve brain swelling - To stop a haemorrhage - Treat epilepsy - Implant a medical device - Deliver medication to your brain (radiotherapy) To Repair : - Blood vessels - Skull fractures - Meninges |
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What are some endocrine complications of a surgery? |
Altered drug metabolism Hypothermia |
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What are some Gastrointestinal complications of a surgery? |
Nausea & Vomiting Distention & Flatulence Paralytic Ileus |
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What are some respiratory complications of a surgery? |
Airway obstruction Hypoventilation Aspirator of vomitus Atelectasis Pneumonia Hypoxaemia |
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What are some cardiovascular complications of a surgery? |
Haemorrhage Hypotension & Shock Thrombosis & Phlebitis Pulmonary Embolism Postural hypotension Arrythmias |
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What are some integumentary complications of a surgery? |
Infection Haematoma Dehiscence Impaired skin integrity |
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What are some fluid and electrolyte complications of a surgery? |
Fluid overload Fluid deficit Hypokalaemia/hyperkalaemia |
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What are some urinary complications of a surgery? |
Urinary retention Infection Renal Failure |
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What is a bone flap? |
When a portion of bone is removed to be later reattached. |
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What is a craniectomy? |
When the bone flap is removed and reattached at a later time via cranioplasty. |
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What is ABCDEFG in nursing priorities? |
Airway Breathing Circulation Disabolity or Drips Drains and Drugs Exposure / Extras Fluids Glucose |
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What percentage of pts experiencehypothermia perioperatively? |
60-90% |
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What are the different ranges of hypothermia? |
ANYTHING LESS THAN 36% ◦Can be mild (34-35c) ◦ Moderate (30-34c) ◦ Severe (<30c) |
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What are some Alternative/complimentary therapies for managing pain? |
- Positioning for comfort (consider surgical procedure) - music, massage, aromatherapy - heat or cold packs - acupuncture, acupressure,hypnosis |
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How does pt education affect pain? |
Reported lower levels of pain and post operative complications |
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What are some causes of hypothermia in theatre? |
- Vasoconstriction due to cold > decreased tissue perfusion - Exposure to cold environment, irrigating fluids, IVfluids in theatre - Exposure of body cavities => loss of heat - General anaesthetic > lowers metabolism - Older age > less muscle mass > lower metabolism > Less heatproduction - Pre-existing conditions e.g. hypothyroidism |
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What can instantly cool a pt in theatre? |
Administering IV fluids |
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What are some systemic effects of hypothermia? |
• decreased CO and blood flow to liver and kidneys • Reduced tissue perfusion due to vasoconstriction to peripherieswhich also increases chance of wound infections & increases risk of pressureinjuries. • increased risk of intra-operative & post-operative bleeding due toimpaired coagulation and platelet function due to effectson the coagulation pathway. • Shivering > increased problems for people with cardiac or respiratorydisease • Longer stay in PARU for re-warming • Can lead to cardiac arrhythmias, ischaemia and cardiac arrest |
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What is a bair hugger? |
Warmed device (mattress) given to warm patients esp. in theatre/PACU
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How much can o2 requirements rise while shivering from hypothermia? |
up to500% |
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How do you manage hypothermia? |
• Active rewarming • Warm blankets and head wrapping • Air warmer or warming mattress (Bair Hugger) • Warmed IV fluids |
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How often do you do OBs on a pt when you are actively rewarming them? |
Every 15min, esp. checking temp and O2 sats |
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What is AF? |
Atrial Fibrillation - Abnormal electrical discharges from atrium - Ventricles respond irregularly - May be transient or persistent ◦ Irregularity = “less atrial kick” & decreased stroke volume |
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What is a simple way to describe transient? |
Something that passes / Not permanent |
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What are some causes of AF? |
Hypertension IHD (ischemic heart disease) heart failure valve disease Thyrotoxicosis |
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What is IHD? |
Ischemic heart disease |
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What are some pharmacological interventions for AF? |
- Beta blockers e.g. atenolol - Ca2+ channel blockers e.g. verapamil, diltiazem (aka cardizem) - Antiplatelet drugs e.g. aspirin; - Anti-coagulation e.g. warfarin ◦ Digoxin no longer first line treatment for AF - Electrical cardioversion - Catheter ablation |
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What is Thyrotoxicosis? |
Aka hyperthyroidism |
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What is a VTE? |
Venous thromboembolism - Blood clots (thrombi) can form in the deepveins => deep vein thrombosis (DVT) -Thrombus detaches from the wall of the vein => lungs => pulmonary embolus (PE) |
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What are two types of VTE? |
DVT |
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What are the symptoms of a DVT? |
- Swelling of leg or vein
- Pain or tenderness in the area - Warmth in skin - Red or discoloured skin |
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What can a LMWH sub cut cause at an injection site? |
Bruising |
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What are some signs/symptoms of a PE? |
- Dyspnoea - Tachypnoea - Haemoptysis - Tachycardia - Chest pain - Anxiety Massive PE - hypotension, pale mottledskin & cyanosis |
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How do we diagnose a PE? |
Through CTPA |
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What is CTPA? |
Computerised Tomography Pulmonary Angiogram |
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How does pulmonary oedema occur? |
Through increase hydrostatic pressure in blood vessels leading to fluid inalveoli |
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How can we prevent PE? |
- Mobilisation - Adequate hydration - Leg exercises - Deep breathing - LMWH - Calf compression with stockings orpneumatic |
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What are the treatments for PE? |
- Surgical - Anti- coagulation therapy - Positioning |
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What are types of surgical treatment for PE? |
- Lobectomy (RARE)
- Thrombectomy - Percutaneous inferior vena cava filter > So clots don't travel |
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What are types of anti-coagulant therapy is used in pts with a PE? |
- Alteplase (tPA) ◦ Activates plasminogen in the clot - clot breakdown - Warfarin ◦ Inhibits a number of factors in the coagulation pathway - Monitor APPT (heparin) or INR (warfarin) |
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How do you manage breathing/pain/anxiety in a PE pt? |
◦ Semi-Fowlers position to aid lung expansion ◦ Administer O2 as ordered ◦ Frequent repositioning ◦ Administer pain relief (opioids) as required ◦ Measures to lower anxiety ◦ Monitor for complications e.g. cardiogenic shock or R ventricular failure |
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What is tertiary intention healing? |
- Delayed primary closure - Wound left open & surgical closure is later when wound is clean |
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What type of would healing includes dehisced wounds? |
second intention |
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What are the 3 main nutrients we consume? |
Proteins Fats |
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Which nutrients are 4cal per gram? |
Proteins and carbohydrates (CHO) |
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Which nutrient is 9cal per gram? |
Fat |
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What is a dietary source of nitrogen? |
Protein
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What can cause intracranial haemorrage/haemotoma? |
◦ Tumours ◦ Trauma ◦ Blood vessel problems e.g. aneurysm ◦ Anticoagulants ◦ Hypertension |
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What are the types of intracranial haemorrage/haemotomas? |
◦ Extra/Epidural ◦ Subdural ◦ Subarachnoid ◦ Intracerebral |
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What signs / symptoms can ICP cause? |
*Depends on the location of the bleed* - Changes in speech - Eyes - Headache - Seizures - Vomiting - Cushing's triad > Irregular RR > High BP - Decreased motor function |
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What is Cushing's triad? |
a clinical triad variably defined as having: Irregular respirations) Bradycardia. Systolic hypertension (Widening Pulse Pressure) |
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If damage is done to the left side of the brain, which side would most symptoms manifest? |
The right side |
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If damage is done to the left side of the brain, which side would your pupil dilate? |
The left side
Pupil dilation is ipsilateral to damage |
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How do you treat intracranial haemorrage/ haematoma? |
- Supportive care - Control of ICP > Fluids, electrolytes, anti-hypertensives - Surgical evacuation ◦ Not always possible |
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How do you manage cerebral oedema? |
- Surgery – craniectomy -Corticosteroids e.g. dexamethasone ◦ Can lead to GI bleeding => Increased risk of infection ◦Not recommended as have no effect on treatment of increased intracranial pressure - Fluid restriction ◦ Can cause hypotension and decreased cerebral perfusion leading to ischaemia ◦Current management is euvolaemia - Hyperosmotic fluids e.g. Mannitol ◦ Diuresis will occur so monitor & maintain fluid balance ◦ Observe for rebound fluid retention and electrolyte imbalances -Sedation – propofol -Diuretics e.g. frusemide (Lasix) - Elevate the head of the bed & maintain head alignment ◦Promotes venous return |
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Define euvolaemia |
Having a normal circulatory or blood fluid volume within their body. |
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Define Diuresis |
increased or excessive production of urine. |
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Define epilepsy |
Recurrent seizures due to uncontrolled electrical discharge inbrain |
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What is the drug of choice for preventing seizures? |
Dilantin - For different types of seizures except absence - Side effects > gum hyperplasia > liver damage > hirsuitism - Sodium valproate (Epilim) - Carbamazepine (Tegretol) - Gabapentin & Pregabalin |
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How do anti-seizure drugs work? |
-Suppresses over-excitability in neurons by: ◦ Stabilising the nerve membrane, altering ion channels, - Enhancingactivity of inhibitory neurotransmitters e.g. GABA & glycine;inhibiting excitatory neurotransmitters e.g. glutamate. |
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What are common ADRs of anti-seizure medications? |
GI upset ataxia headache confusion nystagmus skin rash sedation bone marrow suppression |
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Define Axatia |
The loss of full control of body movementsnystagmus |
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Define nystagmus |
rapid involuntary movements of the eyes |
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How do we manage a seizure? |
AIRWAY FIRST! MAINTAIN IT! - Protect the patient’s head & body - Loosen constrictive clothing - Remove pillows and raise bed rails
- Suction as needed - Observe and record the symptoms Following a seizure: - Reorientate the patient |
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What must we do for a pt following a seizure? |
Re-orientate the pt and let them know what happened |
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What GSC score describes someone in a vegetative state? |
3 |
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What is the gold standard for diagnosing a PE? |
CTPA scan |
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What type of IV fluid is blood? |
Colloid |
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What is an example if an IV plasma filler? |
Albumins |
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What types of WBC are there (5) |
Neutrophils |
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Which cellular components are involved in inflammation and what is their role? |
Blood plasma
WBC |
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What are some examples of inflammatory chemicals? |
- Prostaglandins > Heighten vascular permability Cytokines Histamine |
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What is opsonization? |
Refers to an immune process where particles such as bacteria are targeted for destruction by an immune cell known as a phagocyte |
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How does phagocytosis occur? |
The ingestion of bacteria or other material by phagocytes. (1) invagination (2) engulfment (endocytosis) (3) internalization and formation of the phagocyte vacuole (4) fusing of lysosomes to digest the phagocytosed material (5) release of digested microbial products. (exocytosis) |
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What body part regulates temperature? |
Hypothalamus |
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How does the body increase heat production? |
The hypothalamus when stimulated... - increases metabolic rate, shivering,vasoconstriction |
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How can we body lose heat? |
Radiation – heat loss to air if air cooler thanbody Convection – warm air from body moves awayto be replaced by cooler air e.g. wind chill Conduction – heat loss to a cooler object e.g.body in water Vasodilation, sweating (sympathetic response) |
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What is the pathogenesis of fever? |
- Responses to infection/inflammation - Increased temperature limits release of nutrientsfrom liver which micro-organisms need todivide & slows down bacterial cell division - Pyrogens – bacterial toxins and cytokines e.g. prostaglandin act on hypothalamus - As temperature increases, other chemicals arereleased which try to decrease temperature - Swings in body temperature = rigors |
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Define rigors |
a sudden feeling of cold with shivering accompanied by a rise in temperature, often with copious sweating, especially at the onset or height of a fever. |
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What does fever do to the immune system? |
- Enhances activity ofthe immune system - Reduces availability ofiron & other nutrientsbacteria need to divide |
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What is the mechanism of fever? |
WBC release cytokines e.g. IL-1 > release ofPG in hypothalamus > alters the thermostat |
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What are the benefits of fever? |
Improves immunefunction > Increases release of cytokines > Increases activity of T & B cells > Increases phagocytosis > Decreases nutrients for bacteria |
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What are the risks of fever? |
• Fever is a stressor • Brain damage if sustainedtemperature > 41C • Death > 43C • Febrile seizures (>39C) > Occurs in 3‐5% of all children < 5years |
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What are the 5 immunoglobulin classes? |
IgG - Immunity from infection (cell memory) IgA IgM - Active infection IgE IgD - Allergies |
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What percentage of T Cells make up our circulating lymphocytes? |
80% |
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What are the characteristics of non specific immunity? |
- Response isimmediate -Response is notantigen specific i.e.no antibodiesproduced. - No memory cellsfrom infection |
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What are the characteristics of specific immunity? |
- Responds to specificantigens - Response takes a littletime - Response is antigenspecific i.e. bodymakes antibody inresponse to antigen - Immunity developed tospecific antigen |
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How is Active immunity acquired? |
Exposure to :
- Antigen - Disease - Vaccine |
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How is Passive immunity acquired? |
Via a transfer of antibodies - Maternal antibodies - Antibodies (medicinal dosing) |
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How is blood type cross matching done? |
Exposing donor’s RBCs to sample of recipientsplasma
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What are the blood transfusion types? |
Red blood cells ◦ Replace haemoglobin (anaemia & during surgery) Iron ◦ Essential for Hb production Plasma ◦ Contains proteins and antibodies ◦ Fresh Frozen Plasma (FFP) Platelets ◦ Found in plasma ◦ Replaces clotting factors Cryoprecipitate ◦ Small fraction of plasma that precipitates whenfrozen ◦ Replaces clotting factors (Fibrinogen, Factor VII) |
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What are some blood transfusion complications? |
Fluid overload ◦ Administration of blood too fast or too much fluidfor cardiac/renal function Hypothermia ◦ Cold fluid Allergic reaction ◦ Sensitivity reaction to plasma protein within theblood component being transfused Acute Haemolytic Reaction (intravascularhaemolysis) |
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Why do febrile (non-haemolytic) reactions occur? |
Caused by antibodies to donor leukocytes thatremain in blood ◦ Most common (90% reactions) but should excludeother causes ◦ Fever (more than 1 degree), chills, low back pain,nausea, chest tightness, dyspnoea and anxiety. ◦ Usually 2 hours post commencement ◦ Can prevent/ diminish reaction by using aleukocyte depleted unit (or filter) |
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Why do Acute Haemolytic Reaction (intravascularhaemolysis) reactions occur? |
◦ Donor incompatibility (PRBCs are a liquid organtransplant!) ◦ Antibodies already present in the recipient’splasma rapidly combine with antigens on donorerythrocytes, and the erythrocytes arehaemolysed (destroyed) in the circulation(intravascular haemolysis) ◦ This reaction can occur after transfusion of aslittle as 10 ml ◦ Symptoms consist of fever, chills, low back pain,nausea, chest tightness, dyspnoea, and anxiety.Haemoglobinuria, hypotension, bronchospasm,and vascular collapse may result. |
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What is the most common inducer and maintainer for general anaesthetic? |
Propofol (inducing) |
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|
What 3 ways do general anaesthetics work? |
GABA agonism Open K+ channels Act at NMDA receptors |
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How do local anaesthetics work? |
- Block Na+ channels |
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What is a drug that blocks Ca channels? |
Morphine |
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What is a drug that blocks Na channels? |
Local anaesthetics |
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What is a drug that opens K+ channels? |
General anaesthetic |
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Why do we not give dopamine to people with renal issues or are already taking a dopamine agonist?? |
Dopamine receptors in the kidneys are stimulated and vasodilation occurs |
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If dehydrated, what is the direction of fluid shift? |
ICF to ECF |
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What helps maintain plasma volume? |
Fluid Shift RAAS |
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What does angiotensin II do to maintain plasma volume? |
- vasoconstriction - Increases aldosterone secretion |
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What type of drugs do we give to people with oedema? |
Diuretics and ACE inhibitors |
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Why is heparin given parenternally? |
Because the molecule is large and charged so it cannot cross cell membranes. |
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What is a neuroendoscopy? |
Removal of a tumour through small holes in the skull or through the nose or mouth. - Transnodal: The removal of pituitary tumours |
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What is a transnodal surgery? |
The removal of pituitary tumours through the nose |
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What is the purpose of a shunt? |
To drain fluid from one area of the body to another |
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|
Define aphasia |
inability (or impaired ability) to understand or produce speech, as a result of brain damage. |
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What are some types of brain tumours? |
Gliomas: Arise from the glial cells (brain cells that take care of the neurons). Classified as astrocytoma, oligodendroglioma and ependymoma. Meningioma: Arises from the meninges (membrane that envelopes the brain). Acoustic Neuromas: Arises from the canal connecting the brain to the inner ear. Pineocytoma: Arises from the pineal gland. Pituitary Adenomas: Arises from the pituitary gland. Brain Angiomas: Arises from inside or on the surface of the brain. |
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What is the pineal gland? |
is a small endocrine gland in the vertebrate brain. It produces melatonin, a serotonin derived hormone, which affects the modulation of sleep patterns in both seasonal and circadian rhythms. |
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What is a glioma? |
Tumour arising from the glial cells (brain cells that take care of the neurons). Classified as astrocytoma oligodendroglioma ependymoma. |
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What are the three types of gliomas? |
astrocytoma oligodendroglioma ependymoma. |
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What is an abdominoperineal resection? |
The removal of the anus, rectum and part of the sigmoid colon through incisions made in the abdomen and perineum. The end of the remaining sigmoid colon is attached permanently to the surface of the abdomen. |
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What is the indication for abdominoperineal resection? |
Rectal carcinoma located distal one third of the rectum that requires removal of much of the sigmoid colon . |
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How does one prepare for abdominoperineal resection surgery? |
- Cleanse bowel with laxatives or enemas the evening and morning before surgery. - Full liquid diet may be prescribed 24-48 hours prior to surgery to decrease bulk. - Antibiotics are also administered the day before surgery to reduce intestinal bacteria. - Assess how well the patient understands their diagnosis, procedure and the loss of function after surgery. |
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What are some post-operative care considerations for a pt with an abdominoperineal resection? |
- Assess bowel sounds to identify the return of peristalsis. - Examine stool characteristics. |
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What are some post-operative complications of an abdominoperineal resection? |
- Bowel obstruction - Haemorrhage - Sepsis and shock - Pulmonary complications - Prolapse - Perforation - Stoma retraction - Faecal impaction - Skin irritation |
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Define prolapse
|
a slipping forward or down of a part or organ of the body |
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Define perforation |
the act or process of perforating; specifically : the penetration of a body part through accident or disease
An abnormal opening in a hollow organ or viscus, as one made by rupture or injury. |
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What are post-operative care considerations for a pt with an ORIF? |
- Ensure that the plaster backslab has not been placed too tightly. - Check for drainage in the dressings which may indicate haemorrhage or infection. - Ensure the cast does not become wet. - Check for excessive swelling, cyanosis and loss of sensation. - Assess pain. - Elevate the affected limb for venous return to reduce risk of DVT. |
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What are some nursing interventions for an ORIF? |
- Assess the extent of the damage and function of the body systems.
- Check vital signs and immobilise the affected area to control pain and bleeding. - Administer medications for pain. - Peripheral pulses should be assessed, especially those distal to the affected area. If a pulse is not present, it should be compared to other limbs as well to check if the issue is local or due to systemic hypotension. |
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What are some ORIF complications? |
- Swelling - Haemorrhage and hypovolemic shock. - Compartment syndrome: Sudden decrease in blood flow to the tissues distal to the injured area that can result in necrosis. It is described as a deep, throbbing pain and may be caused by the dressing or plaster backslab being placed to tightly. |
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|
What is compartment syndrome? |
is a serious condition that involves increased pressure in a muscle compartment. It can lead to muscle and nerve damage and problems with blood flow.
Can be caused by a nearby haemorrage |
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|
What are some Nursing responsibilities in resuscitation bay? |
- Ensure equipment is ready for use prior to the patient’s arrival - Maintain a sterile environment by wearing the correct PPE and using sterile procedures. - Assist in assessment and resuscitation. - Administer medications. - Watch for signs of deterioration of the airway, vital signs and level of consciousness. |
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What are the responsibilities involved regarding a surgical drain? |
- Record drainage output and the amount of drainage on the dressing itself. - Spots of drainage on the dressings are outlined with a pen and the date and time is written beside it so that increased drainage is easy to identify. - Excessive drainage should be reported to the surgeon. - Dressings can be reinforced with sterile gauze bandages with the time of their reinforcement being documented. |
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|
What are some characteristics of effective documentation? |
- Write legibly. - Mistakes should be crossed out and signed, no white-out. - Must be objective - Must begin with the date and time. - Should be signed with your name and role. |
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|
What are the characteristics of a healthy stoma? |
- Should be above skin level, red and moist. - There should also be no irritation on the skin surrounding it. - Medication can be administered for diarrhoea and constipation. - Stoma appliance should be changed regularly to avoid leakage - Should be emptied at the same time the patient empties their bladder. |
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|
What should be monitored regarding a urinary catheter? |
- Assess the drainage system to ensure that the catheter is functioning properly. - Fluid intake and output should be recorded hourly to measure renal function and urinary drainage. - Monitor the colour, odour and volume. - Ensure that the tubing is not kinked and that the bag is below the patient for gravity drainage. |
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|
What are the 5 routes that topical medications can be applied? |
- Topical: Applied to skin e.g. minor burns or itching. - Infiltration: Injected into tissue e.g. subcutaneous cyst drainage. - Peripheral Nerve Block Anaesthesia: Injected into nerve trunk e.g. eyes, hands, feet. - Epidural Anaesthesia: Injected between C7 and T10 e.g. obstetric procedures, abdominal, perineal, urological. - Spinal: Injected into cerebrospinal fluid in subarachnoid space (lower than L2) e.g. lower abdomen and extremities. |
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|
What general anaesthetics are given via inhalation? |
nitrous oxide or sevolfurane |
|
|
What general anaesthetic is given via IV? |
propofol is given via IV |
|
|
What are the 5 types of anti-emetics and an example of each? |
- Dopamine antagonists: metoclopramide - Muscarinic antagonists: hyoscine - Anti-histamines: pheniramine - 5-HT3 antagonists: ondansetron - Neurokinin-1 antagonist: aprepitant |
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|
What is amiodarone? |
a class III antiarrhythmic agent used for various types of cardiac dysrhythmias, both ventricular and atrial. |
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|
What is Ceftriaxone? |
A cephalosporin anti biotic ususally given BY IV OR IMI! is used to treat many kinds of bacterial infections, including severe or life-threatening forms such as meningitis. |
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|
What is Dexamethasone? |
A corticosteroid that can be used in treatment of cerebral oedema
a synthetic drug of the corticosteroid type, used especially as an anti-inflammatory agent. |
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What is Gentamicin? |
A bacterial protein synthesis inhibitor in the aminoglycoside group |
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