Acute Care Nursing Practice

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Acute Care Nursing Practice - Lecture notes - NURS1008
Acute Care Nursing Practice (University of Sydney)
Distributing prohibited | Downloaded by GUrpreet Singh (gurpreetc75@gmail.com)

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Medical Administration 6/11/2015 10:43 PM
Medication - substance used in the diagnosis, treatment, cure, relief

or prevention of health alterations.
The medication may be a prescription, non-prescription ( over-the-
counter) or complementary/herbal preparation
Australia's National Medicines Policy aims to maximise an individual's
benefit from a medication regimen, achieve safe, effective and
appropriate use of medications, and optimise medicinal use of
prescription and over-the-counter/complementary preparations to
improve the health outcomes.
Quality use of medications

Judicious use
Appropriate use
Safe use
Efficacious use
Medication Team
Prescribers role
Nurses role
Pharmacists role
Scientific knowledge base

To safely and accurately administer medications
Pharmocokinetics
Pharmocodynamics
Human growth and development
Human anatomy and physiology
Nutrition and mathematics
Application of pharmacology in nursing practice

Names: chemical, generic, trade, classification
Pharmacokinetics as the basis of medications actions

Absorption

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Distribution
Metabolism
Excretion
Types of medication action

Therapeutic effects: expected or predicable physiological
response
Side effects: unintended, secondary effects,
Adverse effects: unexpected effects idiosyncratic reactions,
toxic reactions, allergic reactions
Medication interactions: one medication modifies the action of
another
Medication dose responses

Serum half like: time for medication serum concentration to be
halved
Routes of administration
Oral: sublingual, buccal
Parenteral: subcutaneous, intradermal, intravenous,
intramuscular, epidural, intrathecal, intraossesous,
intraperitoneal, intrapleural, intraarterial
Topical administration: skin, mucous membranes, inhalation,
intraocular
Dosage calculations
Medication administration
Standing orders or routine medication orders
PRN (pro re nata) orders when necessary
Single (one time) orders once only
Stat (statim) orders one only, administered now
Distribution systems

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Stock supply system

Unit dose system
Patient bedside storage system
Electronic medication management system
Medication errors
Any event that could cause or lead to incorrect administration
according to the prescriber's orders as written on the client's
chart.
Occurs when a Registered Nurse fails to follow routine
procedures, such as checking dosage calculations, deciphering
handwriting that is illegible or administering medications with
which the Registered Nurse is unfamiliar
Preventable errors
Using the incorrect drug
Prescribing errors
Administration errors
Incorrect dose
Legal / valid orders

Written or printed in ink
Signed by prescriber and contact number
Full name of recipient, medication, dosage, route and frequency
Instructions for adequate use
Detail the number of times the drug may be dispensed or the
time between repeated administrations
Critical thinking in administering medications

Accountability and responsibility
Check allergies
Ensure documentation
Safe medication administration
5 rights

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5 Rights
Right medication as well as right reason
Right dose
Right patient
Right route
Right time / frequency
3 Checks
The 5 rights are checked 3 times:
1: prior to dispensing the medication
2: after dispensing the medication
3: immediately prior to administering medication to patient
Law, regulation and medications

The National Drugs and Poisons Schedule Committee was established
in 1999 to ensure a uniform approach to the classification of drugs.
This standard has been adopted by all states and territories in
Australia
NSW: Therapeutic goods 1989 (amendments made 2003)
All new drugs imported into Australia must be registered under
this act
List the formation of the drug, its compositions, strengths, size,
dosage forms, indications for use and product names
Poisons and therapeutic goods act 1966 NSW

Medicines, poisons and therapeutic goods regulation 2008
Poisons act: divides available poisons under specific schedules

Poisons list: specifically identifies generic name, drugs or poisons
under each schedule
Poisons regulation: spells out in detail the requirements such as
prescription control and supply
Scheduling in Australia

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Schedule 1 intentionally blank

Schedule 2 pharmacy medicine
Substances for the safe use may require advice form a
pharmacist-pharmacist or licensed person
Schedule 3 pharmacist only medicine
Substances that for safe use require professional advice from a
pharmacist without prescription
Schedule 4 prescription only medicine
Substances for the use or supply of which should be by on the
other of persons permitted to prescribe and should be available
from a pharmacist on prescription
Schedule S4D requires storage and security
Schedule 5 poisons of a hazardous nature
Schedule 6 poison
Schedule 7 dangerous poison
Schedule 8 controlled drug substances which should be available
for use by require restriction of manufacture, supply, distribution,
possession and use of reduce abuse, misuse and psychological and
physical dependence
Schedule 9 prohibited substance
Prescribing
Drugs in the schedule 4 and 8 must be prescribed in writing by a
medical officer
In emergencies a verbal order is permitted but must be written up in
24 hours
Nurse practitioners can prescribe from a predetermined formulae
Administration
Administration of schedule 8 drugs requires addition responsibilities
A witness
Recorded in the register of schedule 8 drugs (DD register)
Patients name
Prescribing drug and dose

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Prescribing doctors name

Date and time to administration
Balance of ampules, tablets, capsules or liquids in supply
Fatal errors
Giving a medication prepared by someone else
Signing a medication given by someone else
Not checking correctly the 5 rights 3 times
Trade vs. generic names
Leaving medication by the bedside once signed the medication is
presumed to be taken
When in doubt check
Listen to the patient
Never guess a route if it is not included
Do not administer a medication from an unlabelled container
Do no administer a medication where you believe the order to be
incorrect

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Medico-legal aspects of consent & pre-operative

care 6/11/2015 10:43 PM
CONSENT
Authorise, approve or permit procedures, intervention and treatment;
person must have decision-making capacity in order to give consent
and have right to refuse treatment and withdraw consent
Why and when?

Consent of a patient prior to commencing a procedure or
treatment is respectful and undertaken as a matter of course by
all health professionals.
It is a legal requirement that heath professionals obtain a
consent from patients prior to any form of consent.
Burden of proof
What can go wrong?

Professional negligence, by act or omission ! not having given
appropriate information
Assault and battery in the absence of informed consent
Breach of contract
How is consent given?

Implied ! assumed consent
Verbally
In writing
Elements of informed and valid consent

Sufficient information for patient to understand the nature and
consequences of the proposed treatment
Material facts that patient would consider important
Informed consent
Balanced information regarding procedure
Risks involved / complications
Alternatives to treatment

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Valid consent
Freely and voluntarily given
Properly informed
Person giving the consent has the legal capacity to give such a
consent
Relates only to the specific procedure consented to
Communication is the key to consent
Consent form
Documented evidence that consent has been given for treatment to
proceed
Used for any procedure with an element of risk
Only as good as the content it represents
Should be signed prior to the patient arriving at the operating suite
Ensuring valid consent

Ask the patient what they understand to be involved
Recognise the patients ay be overwhelmed with information
Provide time for questions
Restate or repeat information
Emergency situation
No consent required when the patient is unconscious or serious ill and
the situation calls for immediate intervention in order to save a
persons life
Must be consistent with good medical practice
Treatment must be reasonable and necessary
Developmental disability
Consent made by legal guardian
Mentally ill patient

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Voluntary admitted yes

Involuntary admitted no
Impaired judgement and intellectual capacity

Person is not capable of understanding and considering treatment, or
making decisions.
As a result of long-term disability or temporary factors guardianship
may apply, if so
The wishes of the person must be paramount "consideration must be
given to the present wishes
of the person
Decisions must be least restrictive of the persons rights and personal
autonomy [consistent with proper care and protection].
Consent of young people

Legal age of consent 18yo
<18yo able to consent to certain conditions
Determined by the childs ability to understand
Emergency treatment may be provided if no parent or guardian can be
reasonably located
Guardianship
Places the care and property of an individual in the hands of another
person.
Public Guardian may make decisions on behalf of the person in the
areas of decision-making authority (i.e. functions) identified in the
guardianship order.
The Public Guardian never makes financial decisions on behalf of the
person under guardianship.
Advanced directives (living will)

Clear and convincing evidence of a patients wishes about future
treatment
Determine the direction or limits of medical treatment in the event that
an individual no longer has the capacity to consent (or refuse).

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Purpose - allow competent individuals to inform health care

professionals of their preferences regarding medical treatment in the
event of their incapacity to communicate.
Refusal of treatment
An adult who is conscious and capable of making decisions has the
right to refuse treatment
PRE-OPERATIVE CARE
Pre-admission clinic (PAC)
Why is it important?
Optimise patient condition preoperatively
Increased effectiveness of service
Decreased cancellations
Reduced stress for patient
Increased reliable education
improved patient satisfaction and experience
Cost effective
Role of nurses
Knowledge of practice standards
Patient assessment skills
Principles of perioperative nursing and management
Anatomy and physiology
Pharmacology
Patient admission criteria
Surgical procedures
WH&S
Medico-legal requirements
Preoperative assessment
Physical examination
Medical and surgical history
Investigations ECG, pathology, imaging, lab test

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Preoperative preparations
NBM solid foods prior 8 hours
Light breakfast prior 6 hours to surgery
Clear fluids prior 2 hours before surgery
Showered
ID band
All jewellery removed or taped
Bladder emptied
Pre-medication given
Glasses, hearing aids, dentures removed
Heal record, valid consent form, obs chart, med chart and completed
preoperative checklist
Old notes and x-rays
Other considerations
Language barriers
Religion
Cultural considerations
Discharge requirements
Benefits of good preoperative preparation

Patients understand more about the surgery
Feel more in control of their actions
Experience less pain and anxiety postop
Better motivated for self care
Require less time in hospital
Have a shortened recuperative period
Preoperative medications
Benzodiazepines reduce anxiety, induce sedation and amnesia
Opioids relieve discomfort during preop procedures
Histamine H2 receptor agonists that increase gastric pH, decrease
gastric volume
Antacids increase gastric pH

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Anticholinergics decrease oral secretions, prevent bradycardia
Patient and family education

Supports patients
Allows time to reflect on information already given and opportunity to
ask questions
Reduces feelings of vulnerability, increases confidence, provides
improved overall experience and better outcomes
Procedural
What to bring
Fasting
Physical prep
Insertion of invasive instruments
Purpose of vital sign monitoring
Analgesia
Process
Admission and traffic flow
For families
Where to wait and how notified once surgery finished
Operation theatre
Noises equipment, communication
Smells cleaning agents, surgical plume
Brightness OT lights
Temperature
Fasting
Minimises the risk of regurgitating the stomach contents
Elective procedures
Individuals as per anaesthetist preferences / patient needs
Only medications with a little water if required as ordered by the
anaesthetist should be taken less than two hours prior

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Health adults
Limited solid food up to 6hrs prior
Clear fluids totally not more than 200mls per hour up to 2hrs
prior
Healthy children over 6 weeks of age
Limited solid food and formula milk up to 6hrs
Breast milk up to 4hrs
Clear fluids up to 2hrs
Healthy infants under 6 weeks of age
Formula or breast ilk up to 4hrs
Clear fluids up to 2hrs prior
Skin preparation
Goal is to decrease bacteria prevent surgical site infection
Preop shower with an antimicrobial solution
Ghlorhexidine gluconate
Povidine iodine but short action than CHG
Preop hair removal
Hair should not be removed unless it impedes surgery
Use of clippers less skin abrasions
Preparation for postop management

Education mobilisation, nutrition, pain management, deep breathing
and coughing exercises, leg exercises
Discharge planning
Begin prior to admission
Patient provided with information in regards to the following:
Duration of stay
Expected recovery period
Restriction of activities
Physiotherapy needed
Other factors to consider
Support network

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Need of carer
Housekeeping, shopping and food

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Surgical intervention: trends, concepts and issues

6/11/2015 10:43 PM
Surgical separations
In 2012-13, 2.5 million or 26% of separations included a surgical
procedure
59% of separations occurred in private hospitals
Urgency of care
12% emergency admissions
82% elective admissions
10% emergency in public hospital ; 2% emergency in private hospitals
Who received care?

Emergency surgery Indigenous Australians and people in very
remote areas
Elective surgery 60% higher for other Australians than indigenous
SES
Public hospital higher in low SES
Private hospital higher in high SES
Appendicectomy most common emergency surgery 89%
Lens extraction most common elective surgery 10%
Length of stay
Emergency admission 7.2 days in public and private hospital
Elective admission 2.3 days for public and 1.9 days for private
Wait times
Indigenous Australians waited longest for elective surgery 41 days
vs. 36 days
Total knew replacement surgery longest median wait time in Aust
201 days
Coronary artery bypass grafting 16 days
Decision to have surgery

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Will it go to plan?
Any complications?
Any risk?
Pain postop?
Will it work?
Reducing anxiety
Patient education
Music therapy 30min preop
ADVANCE (anxiety-reduction, distraction, video modelling & education,
adding parents, no excessive reassurance, coaching and exposure)
Nurses role
Anaesthetic nurse
RN/ EN position (some states performed by an Anaesthetic
Technician)
Responsibility & accountability for care of pts undergoing
anaesthesia (maintaining safety, privacy, comfort & wellbeing)
Ensures safe functioning of anaesthetic equipment
Assist & collaborate with Anaesthetist in conducting a safe
anaesthetic planned approach of care
Aware of principles of infection prevention & control
Provides nursing care associated with administration of
anaesthetic agents, analgesia & IV sedation & monitors
accordingly
Nurse seditionist
Advanced Practice Nurse position (Nurse Practitioner in some
states)
Different to a RN who can administer sedation under the
guidance of a medical officer
Steps toward Certified Registered Nurse Anaesthetist [CRNA]
positions
Currently in operation in SA

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The future
Certified Registered Nurse Anaesthetist [CRNA] role
Functions independently under supervision of Consultant
Anaesthetist
Established in USA
Talks currently under way in Australia
?Minimum education requirements
?Nurse Practitioner role
?Only available in Public Hospitals
Instrument / circulation nurse

RN/ EN position Scrub/ Scout Nurse
Assess individual patient needs & plans patient care
Prepare appropriate equipment & supplies
Create & maintain a sterile field & are vigilant for breaks in
aseptic techniques
Ensure a safe environment for the patient, self & team members
Check instruments & equipment for integrity & good working
order
Have appropriate instruments & equipment at hand
Assist the surgeon as necessary
Ensure items used within the sterile field have been
appropriately processed
Assist in the processing of instruments & equipment
Maintain standard & additional precautions
Kept track of the whereabouts of accountable items
Participate in the documentation of patient care, interventions,
processes & the surgical count
Respond to emergency situations
Work as a member of the perioperative team
Perioperative Surgical Nurse Assistant [PSNA]

RN position
Clinical role

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Evolved due to the changing health environment

Functions under direct supervision of surgeon & is a collaborative
role
Extension of perioperative clinical nursing position
Scope of practice should be clearly documented in each HCF
Assisting with patient positioning
Skin preparation
Draping
Skin retraction
Diathermy under direction
Deep retraction and tissue handling
Assisting with the provision of haemostasis
Insertion and cutting of sutures
Application of dressing
Transfer of patient to bed or trolley
Participation in PACU handover
Post Anaesthetic Care Unit [PACU]

Nurse
RN or EN position (under direct supervision of RN)
Sometimes referred to as the Post Anaesthetic Recovery Unit
[PARU]
High dependency unit
Primary role provide clinical nursing care for the post-op pt
which includes the anticipated prevention & clinical management
of complication
Requires competence (skills & knowledge) of the following:
airway management techniques, ALS, monitoring & resuscitation,
acute pain, N&V, temp control, complications, intraoperative
procedures, modes of anaesthesia, pharmacology & infection
control
Pain management nurse practitioner

Nurse Practitioner position

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Role in Acute Pain Service [APS]

Optimize the care of patients with acute pain
Acts independently & also a member of APS (comprising medical
staff & other health professionals)
Provides comprehensive acute pain management & advanced
nursing care in an expanded nursing role to adults and children
(generally greater than 8 years although dependent on HCF P&P)

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Surgical issues & intraop care 6/11/2015 10:43 PM
Paediatrics
Children are increasingly being cared for in the Day Surgery
environment
Additional requirements with regards to education of parents and child
Parent involvement should be able to stay with child
Pain management and PONV management is important
Specialist Paediatric anaesthetist and surgeon, and nursing staff should
be involved
Anatomy and physiology

Neonates a baby within 44 weeks of age from the date of conception
Infants a child of up to 12 months of age
Child 1 to 12 years
Adolescent 13 to 16 years
Respiratory system
Large head, short neck & a prominent occiput
Tongue is relatively large
Larynx high & anterior, at level of C3 - C4
Epiglottis is long, stiff & U-shaped. It flops posteriorly. The
sniffing the morning air position will not help bag mask
ventilation or to visualise the glottis thus the head needs to be in
a neutral position
Airway narrowest at level of cricoid cartilage
Newborns diaphragmatic breathers ventilatory effort due to
this & nose breathers (so they can breastfeed!)
High metabolic rate
Oxygen demand is higher
Hypoxaemia more rapid in infants & children
Cardiovascular System
Bradycardia is associated with reduced cardiac output
Bradycardia associated with hypoxia should be treated with
oxygen & ventilation initially (when to commence CPR infants
at 60, small child at 40 & large child at 40)

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BP doesnt impact as much as adults (can die with normal BP)
CNS
Thermoregulation - Babies & infants have a large surface area to
weight ratio with minimal subcutaneous fat. They have poorly
developed shivering, sweating and vasoconstriction mechanisms
Renal System
Dehydration is poorly tolerated
Anaesthetic and surgical consideration

What cant be done in a day surgery unit?
Inexperienced surgeon or anaesthetist
Prolonged procedure
Opening of a body cavity
High risk of perioperative haemorrhage/fluid loss
Postoperative pain unlikely to be relieved by oral analgesics
Difficult airway (including obstructive sleep apnoea)
Malignant hyperthermia susceptibility
Sibling of a victim of sudden infant death syndrome
Effective pain management

Pain is a subjective experience and is thus difficult to assess if
communication is not possible.
Assessment relies on using non-specific behavioural and hormonal
signs of distress/stress. It has been shown in neonates and infants that
the use of adequate perioperative analgesia will modify behavioural
and hormonal stress responses and reduce morbidity
Aims of effective pain management
Recognise pain in children
Minimise moderate and severe pain safely in all children
Prevent pain where it is predictable
Bring pain rapidly under control
Continue pain control after discharge from hospital

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Pregnant women
Positioning for the pregnant patient
When pregnant woman, placed in supine position, can result in supine
hypotension syndrome
aortal-caval compression
compression of inferior vena cava decreases venous return
(decreases cardiac output & results in hypotension)
Compression of lower abdominal aorta may occur resulting in
arterial hypotension in lower extremities & decreases
uteroplacental perfusion
Nausea & vomiting, diaphoresis & changes to consciousness may
accompany
To avoid pt placed in slight left lateral position achieved from tilting
bed or placing wedge under left abdo region
Placental membrane
All general anaesthetic drugs cross the placenta and there is no
optimal general anaesthetic technique
Anaesthetic agents can depress the foetal cardiovascular system &
CNS
Volatile agents induce maternal hypotension which can decrease
uterine blood flow & lead to foetal asphyxia
Suxamethonium crosses membrane & therefore crash caesareans
can produce a flat neonate
Opioids have the same effect and the benefit should far outweigh the
risk
Considerations
There is evidence in animal models that many general anaesthetic
techniques cause inappropriate neuronal apoptosis (cell death) &
behavioural deficits in later life
It is not known whether these considerations affect the human foetus
but studies are underway
Goal in pregnant woman requiring surgery is to maintain maternal
oxygenation, perfusion & homeostasis with the least extensive

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anaesthetic (regional anaesthetic is gold standard) that is practical to

assure the best outcome for the foetus
Lactation
Transfer of drugs into breast milk is influenced by protein binding, lipid
solubility and ionisation
Nearly all drugs transfer into breast milk to some extent
Notable exceptions are heparin and insulin which are too large to cross
biological membranes
Some studies indicate that as a result of anaesthetic or analgesic
agents, breastfeeding may be inhibited
Most agents are considered safe due to the low bioavailability of the
drug
Opioids have been shown to increase lactation
Morphine is considered safe due to its fast metabolism
If agents are delivered in high doses, some mothers may choose to
pump & dump prior to recommencing breastfeeding (although now
not considered necessary)
Elderly
Ageing population
Driven by declines in fertility and increased longevity
Emergency setting: no pathway available
Elective setting: routine pathway, pre-admission clinic, discharge
planning
Co-morbidities
Postop testing delirium
Can occur within hours of surgery, potential to last up to 7 days
At least a quarter of elderly patients who develop delirium postop
may continue to have symptoms for up to 6 months after
hospital discharge
Complications: risk of dementia, death, increased length of stay
in hospital and increased risk of new admission to long term care

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Postop care rapid recovery

Rapid mobilization of the patient
Drug dosing: anaesthetics that lead to rapid recovery
Monitoring of intraop depth of anaesthesia
Optimisation of periop fluid management
Appropriate pain management strategies to facilitate early
mobilization and oral nutrition
Physiological changes
Decreased mobility
Decreased elasticity in arteries
Osteoporosis
Delayed healing process
Patient safety
Infection prevention
Gowning and gloving
Face masks
Reprocessing of reusable items
Hand washing
Standard theatre attire
Aseptic technique
Modern sterilising techniques
Cleaning and sterilisation of equipment
Cleaning: low grade decontamination; washing anything that has
come in contact with a patient with neutral detergent
Disinfection: higher grade decontamination; kills microorganisms
using toxic or corrosive substances
Sterilisation: highest grade contamination; kills microorganisms
and their spores using heat, pressure, radiation and chemicals
Saturated steam pressure
Moist heat sterilisation (autoclave)

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Steam heated to 121134 C under pressure with a

holding time of at least 15 minutes at 121 C at 100
kPa or 3 minutes at 134 C at 100 kPa is required
Inactivate all resistant bacterial spores in addition to
fungi, bacteria & viruses & is not expected to
eliminate all prions
Heat & moisture stable items
Low temperature (ethylene oxide (EO or EtO))
# Thermolabile items
# Is a gas used to sterilize objects that are sensitive to
temperatures greater than 60 C and / or radiation
such as plastics, optics and electrics
# Generally carried out between 30 C and 60 C with
relative humidity above 30% and a gas concentration
between 200 and 800 mg/l, and typically lasts for at
least three hours
# Penetrates well, moving through paper, cloth, and
some plastic films and is highly effective. EtO can kill
all known viruses, bacteria and fungi, including
bacterial spores and is compatible with most
materials (e.g. of medical devices), even when
repeatedly applied. However, highly flammable, toxic
and carcinogenic with a potential to cause adverse
reproductive effects
# Most common sterilization method, used for over
70% of total sterilizations, and for 50% of all
disposable medical devices.
Positioning
Pressure injuries
Pressure injuries can impact significantly on the length of stay in
health services, the cost of care, health outcomes and the
comfort and quality of life of the individuals affected.

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3 essential components for preventing pressure injuries

Skin assessment & document
Pressure reduction
# Pressure reducing/relieving materials
# Envelopment: provides pressure reduction by
enveloping irregularities
# Immersion: reduces and redistributes pressure over
a wider area by allow body part to sink into support
surface
# Inspect OT bed mattress on regular basis
# Consider BMI when choosing materials
Minimise shearing forces
# Low friction transfer devices: slide sheets
# Transparent adhesive dressings over bony
prominences: assist preventing skin tears fro those
with fragile skin
# Avoid allowing prep solutions to pool under patient
Surgeon vs. anaesthetist

Surgical:
Optimum access to surgical side
Correct position of operating table
Length of surgery
Anaesthetist
Respiratory function not impaired
Access to IV, arterial and monitoring devices
Physiological stability
Systemic considerations
Respiratory
Positioning may impede chest excursion (gravity causes
anterioposterior diameter to decrease leading to minimal
hypoxia)
Hindered diaphragmatic movements (moves towards head;
TV, FRC reduced)

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Pre-existing resp conditions

Smokers, obese, pregnancy
Cardiovascular
Anaesthetic agents/ meds (alter normal body mechanisms;
some cause constriction/ vasodilation positioning further
complicates this)
Pooling of blood
Pregnancy risk
Occlusion or pressure
VTE
Musculoskeletal
Lack of protective mechanisms
Overstretched, twisted, strained or hyperextension of limbs
Osteoporotic or previous joint surgery pts
Maintenance of body alignment

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Post-operative care 6/11/2015 10:43 PM
Care in recovery
Anaesthetist give report to admitting recovery nurse
Surgeon documents procedure and specific instructions
Priority in recover is:
Monitoring and management of vital functions
Assessing whether the patient is safe to return to ward
Any concerns then alert the patients surgical team/anaesthetist
Potential problems during postop

Airway obstruction
Tongue falling back
Secretions, mucous, blood, vomit
Laryngospasm
Respiratory
Alterations in:
Patency: airway obstruction
Oxygenation
Disruption to gas exchange
Hypoventilation
Bronchospasm
Assessment:
Rate and quality of respirations
SpO2 peripheral capillary oxygen saturation
Auscultate breath sounds in all fields
Management:
Airway adjunct to maintain airway
Sit upright
Oxygen therapy aids removal of anaesthetic and meets
increased oxygen demand
Signs and symptoms
Increased / decreased respiratory rate
Reduced SpO2
Cynosis

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Reduced capillary refill

Reduced air entry to parts of lung
Coughing
SOB
Anxiety
Confusion
Cardiovascular
Alterations in:
Preload
# Hypovaolaemia
# Vasodilation
Contractility
# Cardiac conduction
# Ventricular failure
Afterload
# Hypertension
Assessment:
ECG monitoring
Assess cardiac rate and rhythm
Measure BP, pulse
Assess skin temperature
Management:
Oxygen therapy
Assessment of fluid intake
Coagulopathies (platelet deficiency)
Hypertension
Signs and symptoms
Reduced / increased BP (<90 / >160)
Reduced / increased HR (<60 / >100)
Increased RR
Dysrhymia
Bleeding
Pain

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SOB
Anxiety
Confusion
Neurological
Alterations in:
Altered LOC
Stroke: ischaemic or haemorrhagic
Emboli: air or blood
Hypoxia
Management:
Consider bed rails
Disturbed sensory perception
Signs and symptoms
Altered GSC
Altered AVPU
Combativeness
Confusion
Uncoordinated movements
Slurred speech and difficulty communication
Pupil reactivity
Memory recall and forgetfulness
Nausea and vomiting

May be caused from anaesthetic agents or narcotics
Alterations in:
Delayed emptying
Slowed peristalsis
Management
Anti-emetic medications
IV fluids
Physical assessment for signs of dehydration
Thermoregulation

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Temp <36
Alterations in:
Immune system
Bleeding
Delayed drug metabolism
Malignant hypothermia
Management:
Monitor temperature
Warming blankets
Other
Urinary (beware that patients may experience urinary retention)
Fluid balance
Assess surgical dressings for bleeding, distension to local area
Assess drainage from surgical drains (if applicable)
Assess level of pain
Explain everything to the patient, orientate to environment,
explain procedure is now complete etc.
Transfer of patient form recovery

ISBAR
ABCDEFG assessment
Check medical records
Patient is comfortable
Postop complications following transfer to ward/unit

Respiratory function
Alterations
Atelectasis and pneumonia can occur
Absence of deep breathing due to pain, or sedentary
reclined position and lack of coughing -> development of
mucous plugs in the lungs
Assessment:
Monitor vital signs: respiratory rate, SpO2, auscultation of
chest, capillary refill

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Management:
Encourage regular deep breathing and coughing
Teach patient how to diaphragmatically breath
Regular re-positioning
Mobilisation
Splinting to reduce pain of coughing/breathing
Cardiovascular
Alterations:
Arrhythmias dependent on surgery and other risk factors
Reduced cardiac output bleed and systemic infection
Fluid and electrolyte imbalance
Fluid retention / overload / deficit
Hypokalaemia
Assessment:
Syncope may indicate decreased cardiac output
Oedema
Dehydration
Vital signs
Venous Thromboembolism
Prevention:
Early mobilisation
Lower leg exercises
Anti embolism stockers
Regular repositioning
Physiotherapy
Monitor for swelling, redness, tenderness to legs
Consider risk factors: smoking, surgery,
contraceptive pill, previous VTE
Gastrointestinal
Alterations:
Nausea and vomiting
Imbalanced nutrition

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Assessment:
Active bowel sounds and flatus
Management
Nasogastric tube to decompress stomach
IV fluids
Specific instructions form surgical team clear fluids only,
light diet, NBM
Early ambulation to stimulate bowel
Encourage expulsion of flatus
Paralytic ileus (non-mechanical obstruction)

Lack of intestinal peristalsis and bowel sounds
Management:
# Monitor bowel sounds, NG output, IV fluid input,
keeping patient NBM
# Analgesia
# Anti-emetics
# Oral care moisten mouth, lip moisturising, brush
teeth
Surgical wounds
Assessment:
Knowledge of type of wound, drains and expected drainage
Drainage should change from sanguineous to
serosanguinous to serous with decreasing output
Wound dehiscence may be preceded by sudden brown,
pink, or clear discharge
Local infection
Signs: redness, heat, swelling, loss of function
Symptoms: pain, loss of function
Systemic infection
Signs: raised temp, increase HR, reduced BP, increased
RR, Rigors, febrile convulsions, sweaty

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Symptoms: feeling hot, achy joints, restlessness, pain
Management:
Alert surgical team
Cooling measures
Antipyretic medication
Antibiotics
Adequate hydration
Monitor vital signs
Pressure area care

Prolonged sedentary position put pressure on the skin and
reduce blood flow to that area
Common sites: occiput, elbows, ischial tuberosity
Heels
Constipation
Lack of physical movement
Side effects of medication
Opiates
Complications of surgical procedure
Fear
Pain
Management:
Enema, laxatives
Adequate fluid intake
Fibre diet
Mobilisation
Bowel chart
Urinary retention
Low urine output increase aldosterone and ADH; fluid
restriction pre-surgery; fluid loss during surgery
Loss of sensation
Anaesthetic medications

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Pain
Patient should be able to void up to 200mL postop
Assessment:
Palpate bladder to assess fullness
Use bladder scanner
Encourage oral intake
Pain
Assessment:
P: provoking factors: movement, rest
Q: quality: brining, stabbing, crushing
R: radiation: movement of pain
S: severity of pain: mild to severe
T: Time of onset/ frequency
Treatment:
Continuous analgesia
# Epidural infusion / IV infusion
Intermittent analgesia
# Oral medication / patient controlled analgesia (IV)
Psychological care
Anxiety or depression
Altered body image
Consider alcohol withdrawal
Mood change side effect of medication, dehydration, poor
nutrition, expectations ill aligned

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Wound care 6/11/2015 10:43 PM
Structure of skin
Epidermis
Outer layer consisting of keratinocytes
Loaded with keratin
Eliminated by desquamation after 8-10 days
Basal cell later
Zone in between dermis and epidermis
Dermis
Thickest tissue layer, 2-4mm
Contains collagen and elastin
Contains mast cells, macrophages and lymphocytes
Hypodermis
Subcutaneous fatty tissue
Protects against:
Chemical and mechanical damage
Bacterial and viral pathogens
UV radiation
Prevents excessive loss of fluids and electrolytes to maintain the
homeostatic environment
Types of wounds
Acute wounds
Health tissue is damaged by traumatic means such as surgery,
heat, electricity, chemicals, abrasion
Continuity of skin surface is lost
Eg. burs, donor sites, abrasions, incisional/surgical wounds,
trauma
Chronic wounds
Healing process has stopped or has been interrupted somewhere
in the normal sequence
Secondary intention: wound heal more slowly because volume of
connective tissue to fill the defect is lost eg. pressure ulcer

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Tertiary intention: delayed wound healing used for large

sounds that have not been sutured early or have broken down
Phases of wound healing

Immediate
Haemostasis
Inflammation
Removal of cellular debris and cleaning of wound
Macrophages and leukocytes are dominating cells
Normal duration: 2-3 days
Proliferation
Granulation
Macrophages attract endothelial cells
New capillaries are formed
Fibroblast amount increases and collagen is produced
Red granulation tissue appears in the wound
Epithelialisation
Epithelial cells multiply and migrate across the surface
from the edges
When epithelialisation is complete the would is healed
Maturation
Transformation of the produced collagen will increase the
strength of the connective tissue
Some of the capillaries formed during granulation will disappear
thereby normalising the blood supply
Duration longer than a year
Surgical wound types

Clean
Elective
No acute inflammation
No break-in technique
Respiratory, gastrointestinal, biliary and genitourinary tracts not
entered

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Clean-contaminated
Urgent or emergency case
Elective opening of respiratory, gastrointestinal, biliary or
genitourinary tract
Minor break technique
Contaminated
Non-purulent inflammation
Gross spillage from gastrointestinal tract
Major break in technique
Penetrating trauma
Chronic open wounds to be grafted or covered
Dirty
Purulent inflammation
Preop perforation of respiratory, gastrointestinal, biliary or
genitourinary tract
Penetrating trauma
Wound management
Examination wound appearance (colour, depth, position, pain and
exudate) ; surrounding skin (dryness and maceration) ; general
condition
History medical/surgical, health status, diet, medications,
employment, activity
Four stages of wound management

Define the aetiology
# Vascular chronic venous insufficiency, arterial, mixed,
vasculitis
# Mechanical pressure, friction, shear, trauma, surgical,
infection
Control factors inhibiting the healing process
Intrinsic health status, age, immune function, body build
Extrinsic drying, would temperature, mechanical stress,
chemical stress, foreign bodies, infection
# Preventing surgical site infection

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$ Preop hand hygiene, antibiotics, hair removal

$ Periop theatre wear, wound irrigation and
closure techniques
$ Postop hang hygiene, drains, antibiotics,
dressings
Select appropriate wound dressing
Maintain wound healing
Wound assessment
Wound aetiology
Pain and odour assessment
Wound site
Wound and surrounding skin appearance
Measurement of would depth and undermining
Rational for dressing regime
Wound classification
Red mainly red granulation
Yellow covered with sloughly material consisting of necrotic tissue
and fibrin
Black covered with necrotic tissue, can be soft or dry
Wound exudate
Accumulation of fluids in the wound
Types:
Serous clear, watery plasma
Sanguineous/haemorrhagic indicates fresh bleeding
Serosanguinous/haemoserous mixture of serous and
sanguineous
Purulent thick yellow, green or brown fluid indicative of
infection
Wound cleansing
Goals: remove debris, keep wound clean and protected

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Tap water for low risk wounds

Normal saline irrigation for at risk wounds
Wound dressing technique

Consider contamination sterile equipment
Ideal wound dressing:
Absorbs excess exudate
Maintains high humidity
Allows gaseous exchange
Insulate wound from low temperature effects
Free from contaminants
Maintains slightly acidic pH
Moist healing
Prevents formation of scab
Provides optimal conditions for bodys own wound healing system
Speeds up the healing process
Saves time, money and suffering
Assists with:
Autolytic debridement of the wound
Facilitates wound cleansing
Protects granulation tissue
Encourages epithelisation
Dry healing
Dries out wound
Scab formation
Frequent changes
Mechanical injury to the granulating tissue
Longer healing time

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Acute respiratory illness 6/11/2015 10:43 PM
Lung anatomy
Right lung has three lobes
Left lung has two lobes
Parietal pleura lines the chest wall
Visceral pleura lines the lung surface
Potential space between the pleura with small amount of fluid.
Negative pressure in the pleural space holds the lungs in an inflated
position & stops them collapsing
Indications for lung procedures

Problems with the pleura or pleural space
Spontaneous pneumothorax
pleural effusion
malignant pleural effusion
haemothorax
chylothorax
Empyema
Lung cancer
COPD (with hyperinflation)
Spontaneous pneumothorax
Common in tall thin young men
?an inherent defect in the bodys structure which results in lengthened
chest cavity and lung. This structure makes the lung apex more
vulnerable to gravitational and other stresses
Eg. Marfans syndrome
Results in formation of bullae which can rupture
Diagnosis
Signs & Symptoms
# Pleuritic pain
# Shortness of breath
# Asymmetrical chest movement on inspiration
# Reduced breath sounds on affected side

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CXR
# Loss of lung markings on one side
# Visible edge of lung
Short term management
UWSD
Tension pneumothorax
Often due to a one-way valve developing that allows air to enter the
pleural space, but not leave
Pressure increases displacing vital organs & impacting on the function
of the heart & other lung
Signs & symptoms
Extreme respiratory distress
Tracheal deviation
Congested neck veins
Poor venous return drop in BP
Reduced breath sounds & chest movement on affected side
One of the reversible causes of cardiac arrest!!
Immediate management
large bore needle, 2nd intercostal space mid-clavicular line
Followed by UWSD
Emphysema
Causes
Community/hospital acquired pneumonia Following lung
surgery
Exudative stage
Development of pleural effusion
Fibrinous material forms on the pleural surfaces
Fibrinopurulent stage
May last several weeks
Fibrinous adhesions develop which may cause the fluid to
become loculated
Organisational stage

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Proliferation of fibrinoblasts form an inflexible fibrous coating

preventing adequate lung expansion
Management
Broad spectrum Antibiotic therapy
Drainage using UWSD
Fibrinolytics therapy may be useful in loculated empyemas &
may reduce the need for surgery
Decortication via Video-Assisted Thoracoscopy or open
thoracotomy removes restrictive fibrous layer from lung, chest
wall & diaphragm
Lung cancer
Non-Small Cell Lung Cancer
accounts for about 85% of lung cancers
Includes:
Adenocarcinoma - the most common form of lung cancer in
both men and women.
Squamous cell carcinoma forms in the lining of the
bronchial tubes.
Large cell carcinomas - non-small cell lung cancers that are
neither adenocarcinoma nor squamous cell cancers.
Stages
Stage I: The cancer is located only in the lungs and has not
spread to any lymph nodes.
Stage II: The cancer is in the lung and nearby lymph nodes.
Stage III: Cancer is found in the lung and in the lymph nodes in
themiddle of the chest. Stage III has two subtypes:
IIIA - the cancer has spread only to lymph nodes on the
same side of the chest where the cancer started.
IIIB - the cancer has spread to the lymph nodes on the
opposite side of the chest, or above the collar bone.
Stage IV: The most advanced stage of lung cancer - spread to
both lungs, to fluid in the area around the lungs, or to another
part of the body, such as the liver or other organs.

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Treatment
Most stage I and stage II non-small cell lung cancers are treated
with surgery to remove the tumour.
Neoadjuvant chemotherapy: Receiving chemo before radiation or
surgery may shrink the tumour to make it easier to remove with
surgery, increasing the effectiveness of radiation and destroying
hidden cancer cells at the earliest possible time.
Adjuvant chemotherapy: After surgery, chemotherapy may help
prevent the cancer from returning.
Stage III lung cancer that cannot be removed surgically:
chemotherapy in combination with definitive (high-dose)
radiation treatments.
Stage IV lung cancer: chemotherapy is the main treatment.
In stage IV patients, radiation is used only for palliation of
symptoms.
Small cell lung cancer

accounts for the remaining 15% lung cancers.
More likely to result from smoking
grows more rapidly and spreads to other parts of the body
earlier than non-small cell lung cancer.
They are also more responsive to chemotherapy.
Stages
Limited stage
the cancer is only in one side of the chest (may include
lymph nodes)
Only about 1/3 of people with SCLC are diagnosed at this
stage
patients may benefit from more aggressive treatments
such as chemotherapy combined with radiation therapy to
try to cure the cancer
Extensive stage
cancers that have spread
widely throughout the lung

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to the other lung

to lymph nodes on the other side of the chest to distant
organs (including the bone marrow to fluid within the
pleural space.
Chemotherapy alone is likely to be a better option and
aims to slow progression of disease and symptoms
Lung surgery for cancer

Only 10% of lung cancer presentations are operable
Wedge resection
Preserves more lung tissue Higher risk of recurrence
Lobectomy
Video-assisted thorocoscopy
Cutting / Stapling of tissue via endoscope
Specimens placed in a water-tight bag without breaking up
into smaller sections to prevent seeding of cancer cells
Compared to thoracotomy
No need to divide major muscles of the chest wall
No need for rib spreaders that can lead to rib fractures or
costovertebral joint pain.
Reduced hospital length of stay to 35 days
Post operative care for thorocoscopy / thoracotomy

Care of UWSD
O2 therapy as per SaO2 (Care with CO2 retainers)
Dressings for thorocoscopy sites
IV fluid post op
IV antibiotics (around 4 doses)
SOOB Day 1, walking on the spot, ?Exercise bike
Day 2, walk to bathroom & shower (Educate patient re drain safety,
give them a drain trolley
Home Day 4 ish (if drains out & afebrile)
Poor pain control reduces the depth of breathing & mobility, increases
the chance of atelectasis and makes secretion clearance less affective
therefor more risk of infection

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Patients need to be willing to move, breathe up and cough

Patient controlled analgaesia
Followed by strong oral analgaesia (and aperients!!!)
Ongoing pain may suggest rib fracture or empyema
Under water seal drain

The cannister in the underwater seal section should be filled with
sterile normal saline as marked so that the tube sits just underneath
the fluid level
The suction section should be filled to the level ordered, in cm H2O
(usually 20cmH2O)
The suction should be connected to the LOW suction gauge so that it is
just bubbling gently
The drain should never be lifted above the patients chest unless
clamped.
Observations (hourly)
Bubbling
This means bubbling in the underwater seal chamber NOT
the suction chamber
Bubbling indicates that the patient still has a
pneumothorax
A drain that has stopped bubbling with minimal drainage is
probably ready for removal
If not bubbling on normal respiration, ask the patient to
cough & record bubbling on coughing
Oscillation
Fluid moving up and down the central tube with respiration
in the UWS chamber
It is normal for drains to oscillate on free drainage
When a drain is connected to suction this usually
overcomes the negative pressures created in the thoracic
cavity so that a drain on suction will have minimal or no
oscillation

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Drainage
Observe for amount & trend (more than 300ml/per hour
would be considered excessive)
Sometimes a large amount will drain when you move a
patient eg. From side to side
# Colour of drainage can indicate if active bleeding or
older collection of blood
Cloudiness to the drainage can indicate infection
Observe for clots blocking the tube, especially at joins / Y
connections
Avoid milking the tube extreme negative pressure can
dislodge clots and recommence bleeding. Progressive
clamping along the tube can sometimes move a clot along
Suction
Check the drain is connected to LOW suction at the wall
Make sure it is bubbling GENTLY or your fluid level will
evaporate, reducing the suction
Make sure the suction canister is filled to the prescribed
suction level
A drain that is no longer on suction (ie is on free drainage)
should be open to the air
Tube patency
Check under the blankets!!
Dragging of the tube
Kinking of the tube
Obvious clotting in the tube
When to clamp an UWSD

When you clamp an UWSD it will no longer remove air from the
pleural space and so the patients lung can collapse again if left
clamped on a patient with persistent air leak
Double clamp drains for the shortest time possible When
changing the drainage canister
When removing the drains

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When lifting the drain above chest level

When disconnecting the circuit for any reason
Do not clamp the drains
When transporting a patient
When getting in and out of bed
Dressings and connections

Unless the patient has an allergy to Elastoplast, this is the best
medium to secure a chest drain
The drain insertion site should be cleaned with sterile normal
saline. A keyhole dressing is then placed around the tube &
secured with Elastoplast. An Elastoplast anchor is made to stop
the tube dragging.
Often changed around 2nd daily
Removing an UWSD
Confirm order
Provide IM analgaesia
Remove dressing & position patient comfortably
Find a fried! (2 person procedure)
Open dressing pack & gather steristrips & occlusive (eg Opsite)
dressing & Betadine ointment (or similar)
Don PPE
Swab with NS
Cut the stitch holding in the drain
Cut the ends of the purse string suture so you have two string
ends ready to pull & tie together
Instruct the patient to take a deep breath & hold (practice)
One person quickly pulls out the drain while the other tightens &
ties the purse string
Close with steristrips & Opsite
CXR to confirm no lung collapse
Pneumonectomy

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Via Thorocotomy
Mainly for bronchogenic carcinoma.
tumor is located in a main stem bronchus or the proximal
bronchus intermedius
Or when the tumour extends across a major fissure
Extra pleural pneumonectomy for mesothelioma & thymomas also
includes:
resection of the parietal and visceral pleurae
hemi-diaphragm
ipsilateral pericardium
mediastinal lymph nodes
often coupled with radiation and chemotherapy to improve survival in
both diseases
Care
Need careful pre-op assessment
Do they have good enough lung function to survive on one
lung?
Never lie the patient on their unoperated side
Any leak in their bronchial anastomosis site could cause
fluid to run into their remaining lung
The weight of collected exudate makes it harder for good
expansion of their remaining lung
The UWSD remains clamped! So no suction
(although we may unclamp briefly to check for signs of
haemorrhage)
Pneumothorax is not an issue for these patients
We want exudate to collect & fill the space to prevent
mediastinal shift - Tube often removed Day 1
Why surgery for COPD?

Hyperinflation interrupts the mechanics of normal breathing
Lung Volume Reduction Surgery

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Removal of 20-40% of total lung volume

To reduce the mechanical effects of hyperinflation & facilitate
normal mechanics of breathing
Often done bilaterally so patients return with 2 sets of UWSD!!
On VERY low suction ie 10cm H2O
Prone to large & persistent air leaks
These patients require early mobilisation & planning & pacing of
care
Palliative, Best results with both pre-op & post-op Pulmonary
Rehab!!!
Endobronchial valve insertion

Insertion of one way valve to collapse hyper-inflated regions of lung
Minimally invasive
Day only surgery
Complications of thoracic surgery

Subcutaneous emphysema
Haemorrhage
Intractable air leak
Tension pneumothorax
Infection / empyema
Rib fractures (reduced incidence with thoracoscopy)
Atrial arrhythmias

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Acute cardiac illness 6/11/2015 10:43 PM
Preparing the patient and family for surgery

Talk about what they will look like in CICU - Tubes, ventilation,
monitors, infusions
Not able to talk
Pain will be managed
Talk about timeframes
Time in ICU
Anticipated length of stay (5 days)
Talk about need for deep breathing and coughing
Talk about need to take analgaesia post op
Talk about need for early mobilisation
Preoperative assessment
Baseline observations
In pre-op clinic
CXR, urine sample, ECG, nasal & groin swabs
Any necessary consults eg renal, endocrine.
Spirometry
Height and weight (metric)
Allergies
Temperature, heart rate, resps, blood pressure
Capacity for ADLs, mobility
Recent infections??
Bowel habits
Falls risk assessment
Pressure risk assessment
Discharge planning
Valve patients ... add
Echocardiogram
Dental check
Angiogram only if CHD suspected
Coronary artery bypass graft

Indications:

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Triple vessel disease

Left main disease
Failed angioplasty
Cardiopulmonary bypass
The heart to be stopped (cold cardioplegia solution)
Blood to be warmed or cooled
Oxygenation and pumping of blood to continues
The longer the surgery, the longer the bypass time... the more
complications occur.
Benefits
Comfortable for the surgeon
Bloodless field
Heart doesnt move during surgery more accurate suturing
Myocardial protection (heart cooled & using little oxygen)
Access to all vessels for total revascularistion
Risks
Aortic cannulation
Cerebral emboli
Dissection
Complications of bypass
Off bypass coronary artery grafting

Done on warm, beating heart
Eliminates complications of cardiopulmonary bypass
Eliminates need to cross clamp aorta (%emboli)
Potentially reduces transfusion rates
Potentially reduces cognitive dysfunction
Suturing more difficult
Graft harvest sites

Left Internal Mammary (LIMA) (thoracic region)

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Occasionally RIMA or BIMA

Excellent & prolonged patency
Saphenous vein (leg)
Easily accessible
more susceptible to wear & tear
Radial Artery (arm)
Possible vasospasm
Prolonged patency
Valve repair and replacement

Tricuspid valve: between right atrium & ventricle
Mitral valve: between left atrium & ventricles
Aortic valve: between left ventricle & aorta
Pulmonary valve: between right ventricle & pulmonary artery
Valve repair
Annuloplasty ring support valve
Commissurotomy increase size opening
Valve replacement with tissue valve

Aka heterograft
taken from pig, cow, or human donors.
don't last as long as mechanical valves.
long-term therapy with anticoagulant medication usually isn't
necessary.
Valve replacement with mechanical valve

Lasts longer than tissue valve
Require long term wararinisation
Post operative care

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Secondary prevention
Post CABGs
Statin
Aspirin
ACE inhibitor
Beta-blocker
Cardiac rehabilitation
Risk factor education and modification
Dietician
Pharmacist
Nurse
Physiotherapist
Psychologist
Occupational Therapist
Supervised Exercise programs
Significantly reduces hospital readmission
Significantly reduces future cardiac events
An alternative is patient coaching in a home rehabilitation
framework with patient-set goals

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Acute Pain Management 6/11/2015 10:43 PM
Types of pain:
Acute pain
Aggressive treatment often involving a multimodal analgesic
management including opioids
Chronic pain
Treatment usually non-medications based, opioids are avoided
Focus on CBT
Neuropathic pain
Pain due to damage to nerves
Pathophysiology of pain
Ability of the individual to detect noxious and potentially harmful
stimuli is an important protective mechanism
The process of sending the processing this information in the body is
defined as nociception
Nociceptors are peripheral sensory organs that are responsible for
conduction of pain signals peripherally to the spinal cord centrally;
located in skin, muscle, joints, viscera and meninges.
Tissue damage ! chemical mediators, pro-inflammatory cytokinases
are released ! stimulate the nocicpetors ! transmit pain signals via
afferent nerves to the CNS ! nerves terminate in the spinal cord at
the primary afferent terminal where excitory amino acids such as
substance P, glutamate, and calcitonin gene-related peptide carry
information about the location and intensity of the noxious stimuli to
the dorsal horn of the spinal cord
These substances also contribute to localised vasodilation,
inflammation, oedema and the hyperexcitability /increased sensitivity
of the nociceptors , clinically expressed as localised pain and primary
hyperalgesia
The signal ascends the spinal cord along the ascending pathways
(primarily the spinothalamic tract)
It is then projected into the medulla, thalamus and cerebral cortex of
the brain for higher interpretation
It is at this point that the signal is greatly influenced by emotion,
cognition and behaviour

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With constant bombardment of painful stimuli the post- synaptic

membrane becomes progressively more depolarised thus more
responsive to painful stimuli
This can progress to wind-up and hyperalgesia resulting in:
o An increase in the excitability of neurons in the dorsal horn
o Enlargement of the peripheral area contributing to the dorsal
horn response
o Prolonged duration of response
Modulation of pain
o Descending modulation of pain sensation originates from three
main areas:
# Cortex
# Thalamus
# Brainstem
Stimulation of this system causes inhibition of incoming pain impulses
by:
o Direct action on dorsal horn cells
o Inhibition of excitatory dorsal horn neurons
o Excitation of inhibitory neurons
Serotonin and noradrenalin are the key neurotransmitters involved in

descending inhibition
A second inhibitory system is mediated by endogenous endorphins and
enkephalins, which bind to opioid receptors located around synapses of
the ascending pathways. This inhibits the transmission of pain signals
Adverse physiological effects of acute pain

Physiological effects of pain mediated by metabolic & neuro hormonal
mechanisms (Stress Response)
lipolysis
hyperglycaemia
protein catabolism
increased antidiuretic & catecholamine levels

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immunosuppression
hypercoagulable state
Possible clinical manifestations of Stress Response:
Hypertension
Tachycardia
Splinting
Ventilation perfusion mismatch
Immobility
DVT
PE
Decreased gastrointestinal motility
Water & salt retention
Possible effects of acute pain on the respiratory system:
Atelectasis
Decreased cough
Sputum retention
Infection
Hypoxemia
Possible effects of acute pain on the cardiovascular system:
Tachycardia
Hypertension
Increased myocardial oxygen consumption
Myoardial ischaemia
DVT
Gastrointestinal system
decreased gastric and bowel motility
Genitourinary system
urinary retention
Neuroendocrine system
catecholamines, cortisol, glucagon, growth hormone,
vasopressin, aldosterone and insulin
Pain Assessment
First step to providing effective pain management

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Provides a baseline for ongoing assessment

As nurses we are unable to prescribe analgesic medications, however
through a comprehensive pain assessment (& documentation) we can
assist the medical staff in selecting the appropriate class of analgesia,
dose, frequency, and route of delivery
Nursing staff are also in an ideal position to evaluate the effectiveness
of the prescribed analgesic
In chronic pain there are many validated assessment tools, eg. McGill
Pain Questionnaire comprehensive, take significant time and patient
participation to complete
In acute pain the PQRST mnemonic is quick and useful:
P - Provoked
Q - Quality
R - Region, radiation, relief
S - Severity
T - Time of onset and duration
Provoked
What caused this pain
Quality
What does the pain feel like
helps to diagnose cause of the pain and decide on appropriate
analgesics to prescribe/administer
Nociceptive Somatic Pain:
arising from skin, subcut tissues, bone, joints, muscles,
tendons, mucosal membranes
hot, sharp, stinging
well defined localisation
Nociceptive Visceral Pain:
arising from solid or hollow organs, deep lymph nodes
dull, deep, cramping, colicky
poorly localised, often referral pain present
often associated with vomiting, sweating, BP &
tachycardia

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Neuropathic pain:
arises from injury to the nervous system either at the
periphery or centrally
may be acute or chronic in nature
maybe associated with dysaesthesia, hyperalgesia,
allodynia
may be localised to a nerve / dermatome distribution
often described as burning, tingling, electric shock pain
Region
Where is the pain? Does it move anywhere? What makes it
better or worse?
Useful to diagnose cause of pain
Severity
How bad is your pain?
Ask patient to rate their pain both at rest and on movement
using a validated pain scale
Although subjective, important to have baseline severity scores
Validated pain scales:
VNRS
VAS
VDS
Wong Baker Faces Scale
Abbey pain scale
Choose a tool appropriate for your patient
Time of onset and duration
When did the pain start? Is the pain constant or intermittent?
Has the been already received analgesia, if so what and when?
Assess functionality
No limitation: The patient is able to DB&C without limitation due to
pain
Mild limitation: The patient is able to DB&C but experiences moderate
to severe pain
Significant limitation: The patient is unable to DB&C due to pain, or
pain treatment-related side effects

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Influencing factors
Patients reporting of pain will be influenced by:
Communication skill
Age
Culture
Gender
Previous experiences & severity of disease
Threat value of the pain
External vs internal locus of control
Potential barriers to patients reporting pain

Patients may view pain as a necessary part of the healing process
There may be fears of addiction to opioids therefore pain may be down
played or not reported
Fear of adverse effects such as nausea, pruritus, or constipation
Fear they will be judged as opioid seeking by HCPs / families
Health care professionals as barriers to pain assessment

Busy environments may mean pain assessment is missed or rushed
HCP personal view / experiences with pain
Compassion fatigue is a term used to describe feelings of
disengagement or lack of empathy on the part of the health care
professional. Compassion fatigue, can compromise an individuals
capacity to empathise, engage with and assist patients
When to assess pain

On initial patient assessment
At appropriate time interval post administration of analgesia
Regularly when performing painful procedures
Ongoing and regular Pain is the 5th Vital Sign
Documentation
Record on SAGO whenever observations are done for all patients

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Applicable analgesic observation chart eg. PCA chart, Epidural Infusion

chart
In patients progress notes / EMR
If its not documented - it didnt happen
Medications
Paracetamol
NSAIDs
Opioids
Ketamine
Local anaesthetic
Tramadol
Gabapentinoids
Special considerations
Regular analgesia preferrably
Patients will often have PCAs or regional analgesic infusions for
analgesia
Know if your patient has received a regional block intra-operatively.
Have an understanding of when this will subside and analgesic
requirements may escalate
Monitor patient for post operative complications
Administer PRN analgesics early
Nausea and vomiting not always related to analgesics administer
anti-emetics early
Provide patients with analgesia prior to nursing cares / mobilising,
physio, dressing changes allow time for analgesics to work

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Discharge planning 6/11/2015 10:43 PM
Discharge planning
An actively managed process which - Involves decision making
Balance of risks & benefits
Avoidance of delays.
Discharge planning refers to any process that formally involves the
team or service in transferring responsibility for management from one
group of people to another.
Discharge begins on admission

Early & on-going discharge planning Accurate assessments:
Physical
Psychological
Social
Active involvement of patient & carer
Appropriate, accurate & timely information & advice.
Areas of nurses responsibilities

Communication
Co-ordinating discharge planning
Anticipation & prevention of complications - monitoring physiological
state (observations)
Nutrition & hydration
Personal hygiene & dressing needs
Elimination
Pressure area care
Positioning & movement
Medication
Possible team members involved in discharge planning

Paitnet
Family
Consultant
GP
Nurse

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Physiotherapist
Pharmacist
Social services
Information needs
Personal Cares
Equipment provision
Therapy
Bathing / showering
Transport
Medication
Social services
Assessments by team to determin level of support
Community care assessment
Carers assessment
Home care
Day centre
Equipment
Financial support
Frequent discharge options

Home alone
Home with support (informal carer)
Sheltered Housing independent accommodation with a resident
warden for emergencies
A Residential Home provides 24 hour basic personal care
An Aged Care Facility has qualified nurses & provides 24 hour nursing
care
Palliative Care
An effective transfer should be:

Organised
Planned

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Timely
Patient centred
Cost effective
Appropriate
Co-ordinated
Supported
Follow local policies

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Death & dying 6/11/2015 10:43 PM
Common needs
Management of physical symptoms
Pain
Breathlessness
Fatigue and weakness
Decreased ability to perform activities of daily living and self-
care.
Management of psychological symptoms
Need for social support
Family and carer needs
Culturally specific needs related to language problems and information
disclosure preferences
Spiritual and existential concerns
Reacting to role and function changes (dealing with loss)
Fear and anxiety
Hopelessness vs hope
Information and Communication
Breaking bad news
Dealing with uncertainty
Starting / ceasing treatments
Planning to live / planning to die (ACP & ACDs)
What is a good death?

to have an idea of when death is coming and what can be expected
to be able to retain reasonable control of what happens
to be afforded dignity and privacy
to have control of pain and other symptoms
to have reasonable choice and control over where death occurs
to have access to necessary information and expertise
to have access to any spiritual or emotional support required
to have control over who is present and who shares the end
to have time to say goodbye and to arrange important things
to be able to leave when it is time, and not to have life prolonged
Discussing prognosis and end of life issues

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Clinicians need to provide information in a way that assists

patients/families to:
make appropriate decisions
be informed to the level that they wish
set goals and priorities
cope with their situation
Barriers to discussing prognosis and end of life issues

Lack of training
Stress
Lack of time
Fear of upsetting the patient and family
Hopelessness regarding unavailability of further curative treatment
PREPARED
Prepare for the discussion
Relate to the person
Elicit patient and caregiver preferences
Provide information
Acknowledge emotions and concerns
Realistic hope
Encourage questions
Document

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Advance care planning

Process of planning for future medical care
Process, not a discrete event
reviewed with patient and staff
updated regularly with each review and record
Exploration and documentation of values, goals during which
patients...
Identify and clarify their personal values
Express goals about health and medical treatment
Identify the care they would like, or not like, to receive in various
situations
Determination of proxy decision-maker
Makes health care decisions on patient's behalf in the event they
cannot make decisions for themselves

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Body changes indicating impending death

Circulation
Mottling of lower extremities
Mottling is sometimes used to describe uneven discoloured
patches on the skin of humans as a result
Of cutaneous ischemia (lowered blood flow to the surfaces of the
skin).
Skin
Clammy
Dusky, grey coloration
Eyes
Discoloured
Deeper set
Bruised appearance
Monitor skin changes
Oedema
Bruising
Dryness
Venous pooling
Avoid shearing forces
Reposition frequently

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Gentle massage or lotion application may be provided by the family
Immediately after death

The body is laid flat
Allow the family to say goodbye
Explain the procedure of what will happen next doctor needs to
certify death (paper work also differs for either a cremation or burial)
Gently encourage the family to see the body, enquire whether anyone
else will be coming
The body is washed and a shroud is placed on the body and wrapped
before transfer to the morgue/ funeral parlour (community setting)
Respect any religious and cultural beliefs
Common grief reactions

Psychological ..disbelief, confusion, a sense of the deceaseds
presence., anxiety, fear ,sadness, guilt.
Physical ...chest tightness, hollow inside, loss of appetite ... insomnia,
digestive problems
Behavioural ...crying , sleep disturbances, sighing, forgetful
Spiritual .... all hope appears lost, life has lost its meaning
Role of coroner
Identity of the deceased person
Date of death
Place of death
Cause of death
Manner of death

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EXAM!! 6/11/2015 10:43 PM
Based on 2 scenarios
2 sections
Section 1: 14 short answers (62 marks)
Section 2: 8 short answers (38 marks)
Astrid
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Lab
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Acute Care Nursing Practice - Lecture notes - NURS1008

Acute Care Nursing Practice (University of Sydney)

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Medical Administration 6/11/2015 10:43 PM

Medication - substance used in the diagnosis, treatment, cure, relief

Quality use of medications

Scientific knowledge base

Application of pharmacology in nursing practice

Pharmacokinetics as the basis of medications actions

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Types of medication action

Medication dose responses

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Stock supply system

Legal / valid orders

Critical thinking in administering medications

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Law, regulation and medications

Poisons and therapeutic goods act 1966 NSW

Poisons act: divides available poisons under specific schedules

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Schedule 1 intentionally blank

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Prescribing doctors name

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Medico-legal aspects of consent & pre-operative

Why and when?

What can go wrong?

How is consent given?

Elements of informed and valid consent

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Communication is the key to consent

Ensuring valid consent

Mentally ill patient

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Voluntary admitted yes

Impaired judgement and intellectual capacity

Consent of young people

Advanced directives (living will)

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Purpose - allow competent individuals to inform health care

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Benefits of good preoperative preparation

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Anticholinergics decrease oral secretions, prevent bradycardia

Patient and family education

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Preparation for postop management

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Surgical intervention: trends, concepts and issues

Who received care?

Appendicectomy most common emergency surgery 89%

Lens extraction most common elective surgery 10%

Decision to have surgery

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Instrument / circulation nurse