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Older Adults Pt 2 > 3.3 Postoperative Care > Flashcards

3.3 Postoperative Care Flashcards

1
Q

Post-Anesthesia Care

A
  • Patients either go to PACU or Critical Care for recovery
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2
Q

3 Phases of Post-Anesthesia Care

A
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3
Q

Phase 1

A
  • Intense monitoring and care in the immediate post-op period
    “Intensive Care Setting”
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4
Q

Phase 2

A
  • Transitional period to prepare patients for transport to inpatient units.
  • Patient and family are educated on post-op care and surgeon’s instructions
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5
Q

Phase 3

A
  • Phase 2 and 3 are often combined

- Patient is prepared for self-care and discharged from the facility

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6
Q

PACU Nurse Roles

A
  • Responsible for monitoring/caring for post-op patient
  • Receive hand-off from OR team and anesthesiologist
  • Review pertinent and baseline information upon admission
  • Assess airway, respiratory, cardiovascular function
  • Assess skin color, LOC, ability to respond to commands
  • Re-assess vitals and status every 15 minutes as necessary
  • Administer post-op analgesia
  • Provide handoff to other units or discharge patient
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7
Q

PACU Admissions Handoff Report from Anesthesiologist

A

Information
- Name, Age, Surgeon, Procedure, Anesthesia Care Provider, Patient History, Allergies, Major Medical History, Anesthetic’s Used, Pain Medications Given, IV Fluids Given, Urine Output.

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8
Q

Nursing Management in PACU

A
  • On-going evaluation and stabilization of patient
  • Prevent complications after surgery
  • Provide care for patient until recovery from anesthesia complete
  • Resumption of motor/sensory function, orientation, stable VS, absence of hemorrhage or other complications in surgery.
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9
Q

Specific Post-Op Nursing Responsibilities

A
  • Assessment
  • Support of respiratory function
  • Administration of oxygen, coughing, deep breathing
  • Positioning to prevent aspiration
  • Monitoring Vitals
  • Keeping patients warm
  • Assess return of normal bowel sounds and urinary output
  • Preform postoperative teaching
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10
Q

Post-Op Nurse Outpatient Surgery Responsibility

A
  • Discharge planning/assessment
  • Written instructions for follow-up care
  • Wound care
  • Medications and diet
  • Patients cannot drive home or be discharged alone
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11
Q

Gerontologic Considerations

A
  • Hypoxia, Hypotension, Hypoglycemia more common
  • Frequent monitoring is required
  • Increased confusion occurs (reorientation needed)
  • Dosage of medication should be adjusted
  • Hydration important (maintaining fluid balances more challenging)
  • Increased likelihood of post-op confusion/delirium
  • Older adults may respond differently to pain medication
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12
Q

Assessment

A
  • Airway patency
  • Respiration rate, breath sounds, supplemental pulse, pulse oximetry
  • Pulses, skin color/temperature, capillary refill, ECG, bleeding
  • Take vital signs every 15 minutes.
    ISSUE - Systolic BP less than 90 or greater than 160
    ISSUE - Pulse under 60 or over 120
  • Assess pain levels
  • Assess LOC, movement and sensation, strength
  • Urine output, amount, color, bladder distension
  • Abdominal distension, bowel sounds.
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13
Q

Sample PACU Nursing Diagnosis

A
  • Risk of ineffective airway clearance
  • Acute pain
  • Decreased cardiac output
  • Activity intolerance
  • Impaired skin integrity
  • Ineffective thermoregulation
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14
Q

Interventions

A
  • Monitor/manage ABC’s
    PRIORITY
  • VS, temperature, gag/swallow reflex, LOC, skin color, capillary refill, pain, surgical site, check all invasive lines/tubes, monitor drainage from tubes, monitor I&O
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15
Q

POOR OXYGENATION AND PERFUSION SIGNS

A
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16
Q

CNS

A
  • LOC/Mental Status is the first system to be affected by poor oxygenation and perfusion.
  • Restlessness, agitation, muscle twitching, seizure and coma
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17
Q

CV

A
  • Hypertension or Hypotension
  • Tachycardia or Bradycardia
  • Dysrhythmias
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18
Q

Integumentary

A
  • Cyanosis
  • Prolonged capillary refill
  • Flushed/Moist skin
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19
Q

Respiratory

A
  • Use of accessory muscles to breathe
  • Abnormal breath sounds
  • Increased respiratory effort
  • Dropping PaO2 saturation
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20
Q

Renal

A
  • Urinary output is key indicator for poor perfusion

- Output less than 0.5mL/kg/hour

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21
Q

Maintaining Patent Airways

A
  • Provide supplemental oxygen as needed
  • Assess breathing by placing hand over face to feel air movement
  • Keep head elevated 15-30 degrees unless contraindicated
  • Suctioning as required
  • Turn patient to side if vomiting occurs
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22
Q

Positioning

A
  • Unconscious patients should be kept in lateral recovery position
  • Reduces risk of aspiration and airways open
  • Once conscious reposition to supine with HOB elevated
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23
Q

Hypoxemia

A
  • PaO2 less than 60 mmHg

- Most common causes in post-op is atelectasis, pulmonary edema, pulmonary embolism, aspiration, bronchospasm

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24
Q

Atelectasis

A
  • Most common cause of hypoxemia
  • Thick secretions stimulated by anesthetics that block bronchioles with collapse of alveoli
  • SOB, cough, Low Grade Fever
    IMMEDIATE ACTIONS
  • Humidified O2 Therapy
  • Deep breathing and coughing
  • Incentive Spirometry
  • Early Mobilization
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25
Q

Pulmonary Edema

A
  • Buildup of fluid in alveoli (limits gas exchange)
  • Results from fluid overload, left ventricle failure, prolonged airway obstruction
  • Decreased O2 Saturation, crackles, infiltrates on chest x-ray
    IMMEDIATE ACTIONS
  • Elevate HOB (if not related to airway obstruction)
  • O2 Therapy
  • Diuretics
  • Fluid Restriction
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26
Q

Pulmonary Embolism

A
  • Thrombus lodged into pulmonary arterial system
  • Results from hemoconcentration, left ventricular failure, prolonged immobilization.
  • Acute tachypnea, dyspnea, tachycardia, hypotension, decreased o2 saturation, bronchospasm
    IMMEDIATE ACTIONS
  • Elevated HOB
  • O2 Therapy
  • Cardiopulmonary Support and O2 Therapy
  • Anticoagulants
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27
Q

Aspiration

A
  • Inhalation of gastric content into lungs
  • May cause laryngospasm, infection, and pulmonary edema
  • Unexplained tachycardia, decreased o2 saturation, bronchospasm, atelectasis.
    PREVENTION IS GOAL
    IMMEDIATE ACTIONS
  • Elevate HOB
  • Cardiopulmonary Support
  • Antibiotics
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28
Q

Bronchospasm

A
  • Increased smooth muscle tone with closure of small airways
  • Wheezing, dyspnea, tachypnea, decreased O2 sat, use of accessory muscles, hypoxemia
    IMMEDIATE ACTION
  • O2 Therapy
  • Bronchodilators
  • IV anti-cholinergics
  • IV steroids
    IF TREATMENT RESISTANT IV EPINEPHRINE SHOULD BE ADMINISTERED
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29
Q

Airway Obstruction

A
  • Muscular flaccidity with decreased LOC
  • Tongue falls backwards and occludes pharynx due to anesthesia or muscle relaxants
  • Use of accessory muscles, snoring respirations, decreased air movement, laryngospasm, crowing respirations, inspiratory stridor.
    IMMEDIATE ACTIONS
  • Head tilt/Jaw Lift
  • Reintubation
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30
Q

Hypoventilation

A
  • Respiratory depression from anesthesia, or mechanic restriction from position, dressing, obesity.
  • Shallow respirations, decreased breath sounds, decreased oxygen saturation, rising CO2 levels
    IMMEDIATE ACTIONS
  • PREVETION IS GOAL
  • Elevate HOB
  • Administer O2
  • Reverse Opioids
  • Mechanical Ventilation
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31
Q

Cardiovascular Stability

A
  • Monitor CV status
  • Assess IV lines
  • Recognize potential hypotension and shock
  • Systolic less than 90 mmHg should immediately be reported
  • BP with downward trend of 5 mmHg each 15 minutes should also be reported
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32
Q

Hypovolemic Shock

A
  • Low BP
  • Decreasing pulse pressure
  • Rapid/Weak/Thready Pulse
  • Cool/Moist Skin
  • Pallor/Cyanosis
  • Rapid Respirations
  • Altered Mental Status
  • Decreased and Concentrated Urine
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33
Q

Pain Signs

A
  • Increased pulse/bp
  • Increased RR
  • Diaphoresis
  • Restlessness
  • Moaning/Crying
  • Confusion (Especially in older adults)
34
Q

Patient-Controlled Analgesia

A
  • Common for acute post-op patients
  • Ordered by provider or anesthesiologist
  • Managed by anesthesia in non-surgical patients
  • Mostly opioids are used (morphine, fentanyl, hydromorphone)
  • Delivers calculated preset continuous infusion
  • Patient can click a button to deliver pre-set bolus dose of analgesics
  • Proxy can be designated to use the PCA
  • There is a lock-out time after clicking button to prevent overdose
35
Q

PCA

A
  • Shown to be more effective then intermittent IV or IM dose
  • Gives patients sense of control over pain management
  • Decreases anxiety/depression
36
Q

Role of Nurse in PCA

A
  • Determine patients baseline pain levels, vs, LOC, mental status, level of sedation
  • Assess for prior opioid use and medical allergies
  • Immediate access to naloxone (Narcan)
  • Patient teaching on how and why to use PCA
37
Q

ON-Q Pump

A
  • Sub-Q pain management system
  • Delivers local anesthetic to surgical site
  • Rate is determined by physician
38
Q

On-Q Pump

A
  • Less need for narcotics
  • Quicker return to normal activities
  • Less chance of grogginess
  • Greater mobility and ambulation
39
Q

Aldrete Score

A
  • Monitored every 10 minutes during phase 1 PACU
  • Used to assess if a patient can be discharged to inpatient unit or phase 2 PACU
  • Criteria include consciousness, stable vital signs, no excess bleeding or drainage, no respiratory issues, o2 saturation over 90%
40
Q

Handoff Report to Floor/Unit Nurse

A 
Should follow SBAR
S - Situation
B - Background
A - Assessment 
R - Recommendations
41
Q

Inpatient Unit

A
  • Upon arrival, assist to bed
  • Vital signs
  • Assessment compared to PACU report
  • Oriented to room, call bell, lowered bed
  • VS measured every 15 minutes for an hour
42
Q

Prevention of Respiratory Complications

A
  • Deep breathing to prevent alveolar collapse
  • Inhale deeply through nose, hold, and exhale completely through mouth
  • Patient hands should be slightly above abdomen
  • Do this 10 times every hour while awake
  • Change positions every 1-2 hours
  • Ambulation as soon as possible
  • Adequate Analgesia
  • Adequate hydration to keep secretions thin and loose
43
Q

Effective Coughing

A
  • Deep breath, hold for 2-3 seconds, and use abdominal muscles to forcefully expel air
  • Abdominal/chest incisions should be splinted with pillow, arms, or hands to decrease pain.
44
Q

Prevention of CV Complications

A
  • Leg exercises to maintain blood flow
  • Sequential Compression Devices to prevent blood clots
  • Anti-coagulants for high risk patients
45
Q

Postoperative Neurological Assessment

A
  • Focused on orientation and LOC
  • Glasgow coma scale if indicated
  • Pupillary check
  • Sensory and Motor Status
46
Q

Urinary Assessment

A
  • Assess color, amount, retention and oliguria
  • Consistency and odor (infection such as UTI)
  • Output should be 0.5mL/kg per hour with indwelling catheter
  • 30mL/Hr at least
  • Assess for bladder distension, bladder scan, and catheterize patient if they have not voided in 6-8 hours.
47
Q

GI Assessment

A
  • Resume oral intake once gag and swallow reflex return
  • While NPO IV fluids maintain needs
  • Frequent mouth care
  • Ambulation encourage gastric motility
48
Q

Nausea

A
  • Immediately turn patient to their side to promote mouth drainage and prevent aspiration
  • Administer antiemetic’s or prokinetic drugs
49
Q

Postop Ileus

A
  • Temporary impairment of gastric and bowel motility after major abdominal surgery.
  • Assess for distension due to decreased peristalsis
50
Q

NG Tubes

A
  • Inserted during surgery to drain stomach, promote GI rest, allow GI tract to heal, provide route for enteral feeding, monitor gastric bleeding, prevent intestinal obstruction
  • Drained material assessed for 8 hours and counted as patient output
51
Q

Altered Temperature

A
  • Temp should be measured every 4 hours
  • Asepsis with surgical wounds and IV sites
  • If fever develops obtain culture
  • Chest X-ray may be needed
  • Antibiotics
  • Antipyretic medications
52
Q

Progressive Ambulation

A
  • Early ambulation is most significant nursing care measure to prevent post-op complications
  • Allow patient to sit in high fowler
  • Help patient sit and dangle legs off side of bed
  • Evaluate symptoms of orthostatic hypotension or hypotension
53
Q

First Dressing

A
  • Surgeons are usually the one to change original dressing

- If you note bleeding, reinforce the dressing and mark the area of bleeding

54
Q

Drainage

A
  • Note the type, amount, color, consistency, and odor of drainage on dressing
  • Expected to change from sanguineous to serosanguineous to serous
  • Drainage is recorded as output
55
Q

Dressing Change

A
  • Sterile technique
  • Determine type of dressing material required before removing existing dressing
  • Assess for infection, number of drains, overall appearance of wound
  • Note drainage at time of dressing change
56
Q

Montgomery Straps

A
  • Used when frequent dressing changes are anticipated

- Prevents skin irritation from tape removal

57
Q

Surgical Drains

A 
Penrose - Passive drainage onto dressing
Jackson Pratt (JP) - Non-mechanical vacuum bulb
Hemovac - Non-mechanical vacuum chamber
58
Q

Hematomas

A
  • Pooling of blood outside blood vessel

- Develops when drainage blood accumulates under incision

59
Q

Dehiscence

A
  • Separation of previously approximated wound edges
  • May occur with wound infection
  • Brown, pink, or clear drainage may precede dehiscence
  • Wound cultures should be obtained
  • Surgeon should be notified immediately
60
Q

Evisceration

A
  • Protrusion of abdominal organs from opened incision

- Cover area with sterile dressing soaked in sterile saline and notify surgeon immediately

61
Q

Fentanyl (Sublimaze, Duragesic)

A
  • 100 times more potent than morphine.

- Synthetic opioids like fentanyl are the most common drug involved in overdose deaths

62
Q

Sublimaze (Parenteral)

A
  • Used for severe pain

- Used for moderate sedation

63
Q

Duragesic (Transdermal)

A
  • Patch activated by body heat

- New patch over non-bony area every 72 hours

64
Q

Transmucosal

A 
- Absorbed across mucous membrane
Actiq - Lozenge on a stick
Onsolis - Buccal Film
Fentora - Buccal Tablet
Abstral - Sublingual Tablets
65
Q

Meperidine (Demerol)

A
  • No longer frequently used
  • Significant toxic metabolite so use with caution
  • Used for post-operative shivering
66
Q

Methadone

A
  • Used for treatment of pain and opioid addicts
67
Q

Hydromorphone, Oxymorphone, Levorphanol

A
  • Semi-synthetic opioid analgesic
  • More potent than morphine but shorter duration
  • Greater sedation
  • Available in parenteral and oral forms
  • Moderate to Severe Pain
68
Q

Codeine

A
  • 10% converted to morphine in liver
  • Used for pain and cough suppression
  • Usually administered orally but can be parenteral
  • 30 mg codeine equals 325 mg acetaminophen
69
Q

Oxycodone

A
  • Long-acting analgesic
    Roxicodone - Immediate release
    OxyContin - Controlled release
70
Q

Hydrocodone

A
  • Most widely prescribed pain medication in the US
  • Used in combination with aspirin, acetaminophen, ibuprofen
  • Available as tablets, capsules, syrups
71
Q

Tapentadol (Nucynta)

A
  • Analgesic equivalent to oxycodone but causes less constipation
72
Q

Agonist-Antagonist opioid

A
  • Effective as analgesic with less potential abuse
73
Q

Pentazocine (Talwin)

A
  • Incomplete reversal of cardiovascular, respiratory, and behavioral depression induced by morphine
  • 50 mg orally equates to analgesics of 60 mg of codeine
74
Q

Nalbuphine (Nubain)

A
  • Buturphanol
  • Used during labor for pain
  • 7 day patch or sublingual film (Suboxone)
75
Q

Clinical Issues with Opioids

A
  • Physical Dependence - Abstinence syndrome when withdrawn (not addiction)
  • Abuse - Drug use inconsistent with medical or social norms
  • Addiction - Behavioral pattern by continued use of psychoactive drugs despite physical, psychological, or societal harm
76
Q

Naloxone (Narcan)

A
  • Antagonist to opioids with onset within 2 minutes
  • Metabolized in liver and can cross placenta
  • 0.4mg - 2mg original dose via IV
  • Can also be Sub-Q or IM
  • Endotracheal, Nasal, Sublingual, Intralingual, and submental routes
  • Reversal of Opioid Overdose
77
Q

Non-Opioid Centrally Acting Analgesics

A
  • Provide pain relief unrelated to opioid receptors

- Do not cause respiratory depression, physical dependence, or abuse

78
Q

Tramadol (ultram)

A
  • Combination of Opioid and Non-Opioid Mechanisms
  • Has potential for abuse
    Adverse Effects
  • Drowsiness, Sleep Pattern Changes, Mood Alterations
  • Shaking, Muscle Tightness, Nervousness
  • May increase suicidal thoughts
79
Q

Clonidine (Duraclon)

A
  • Alpha 2 adrenergic Agonist
  • Used in combination with opioids
  • Analgesic by blocking pain signal transmission
  • Epidural, Oral, Transdermal, Extender Release
    Adverse Effects
  • Cardiovascular
    (hypotension, rebound hypertension, bradycardia)
80
Q

Antiemetic and Prokinetic Medication

A
  • Antiemetic medications help with nausea and vomiting that occurs with anesthesia
  • Can also be used for patients receiving chemotherapy
  • Prokinetic drugs also help with nausea
81
Q

Metoclopramide

A
  • Peripheral cholinergic agonist and dopamine antagonist

- Most commonly used antiemetic/prokinetic drug

82
Q

Prokinetic Drugs

A
  • Improve esophageal and gastric motility
  • Decrease gastric reflux
  • Accelerate gastric emptying
  • Limited to upper GI tract, esophagus, and stomach

Older Adults Pt 2 (17 decks)

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