3.3 Postoperative Care Flashcards
1
Q
Post-Anesthesia Care
A
- Patients either go to PACU or Critical Care for recovery
2
Q
3 Phases of Post-Anesthesia Care
A
3
Q
Phase 1
A
- Intense monitoring and care in the immediate post-op period
“Intensive Care Setting”
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
5
Q
Phase 3
A
- Phase 2 and 3 are often combined
- Patient is prepared for self-care and discharged from the facility
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
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.
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.
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
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
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
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.
13
Q
Sample PACU Nursing Diagnosis
A
- Risk of ineffective airway clearance
- Acute pain
- Decreased cardiac output
- Activity intolerance
- Impaired skin integrity
- Ineffective thermoregulation
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
15
Q
POOR OXYGENATION AND PERFUSION SIGNS
A
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
17
Q
CV
A
- Hypertension or Hypotension
- Tachycardia or Bradycardia
- Dysrhythmias
18
Q
Integumentary
A
- Cyanosis
- Prolonged capillary refill
- Flushed/Moist skin
19
Q
Respiratory
A
- Use of accessory muscles to breathe
- Abnormal breath sounds
- Increased respiratory effort
- Dropping PaO2 saturation
20
Q
Renal
A
- Urinary output is key indicator for poor perfusion
- Output less than 0.5mL/kg/hour
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
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
23
Q
Hypoxemia
A
- PaO2 less than 60 mmHg
- Most common causes in post-op is atelectasis, pulmonary edema, pulmonary embolism, aspiration, bronchospasm
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
25
Pulmonary Edema
- 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
26
Pulmonary Embolism
- 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
27
Aspiration
- 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
28
Bronchospasm
- 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
29
Airway Obstruction
- 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
30
Hypoventilation
- 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
31
Cardiovascular Stability
- 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
32
Hypovolemic Shock
- Low BP
- Decreasing pulse pressure
- Rapid/Weak/Thready Pulse
- Cool/Moist Skin
- Pallor/Cyanosis
- Rapid Respirations
- Altered Mental Status
- Decreased and Concentrated Urine
33
Pain Signs
- Increased pulse/bp
- Increased RR
- Diaphoresis
- Restlessness
- Moaning/Crying
- Confusion (Especially in older adults)
34
Patient-Controlled Analgesia
- 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
PCA
- Shown to be more effective then intermittent IV or IM dose
- Gives patients sense of control over pain management
- Decreases anxiety/depression
36
Role of Nurse in PCA
- 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
ON-Q Pump
- Sub-Q pain management system
- Delivers local anesthetic to surgical site
- Rate is determined by physician
38
On-Q Pump
- Less need for narcotics
- Quicker return to normal activities
- Less chance of grogginess
- Greater mobility and ambulation
39
Aldrete Score
- 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
Handoff Report to Floor/Unit Nurse
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Should follow SBAR
S - Situation
B - Background
A - Assessment
R - Recommendations
```
41
Inpatient Unit
- 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
Prevention of Respiratory Complications
- 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
Effective Coughing
- 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
Prevention of CV Complications
- Leg exercises to maintain blood flow
- Sequential Compression Devices to prevent blood clots
- Anti-coagulants for high risk patients
45
Postoperative Neurological Assessment
- Focused on orientation and LOC
- Glasgow coma scale if indicated
- Pupillary check
- Sensory and Motor Status
46
Urinary Assessment
- 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
GI Assessment
- Resume oral intake once gag and swallow reflex return
- While NPO IV fluids maintain needs
- Frequent mouth care
- Ambulation encourage gastric motility
48
Nausea
- Immediately turn patient to their side to promote mouth drainage and prevent aspiration
- Administer antiemetic's or prokinetic drugs
49
Postop Ileus
- Temporary impairment of gastric and bowel motility after major abdominal surgery.
- Assess for distension due to decreased peristalsis
50
NG Tubes
- 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
Altered Temperature
- 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
Progressive Ambulation
- 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
First Dressing
- Surgeons are usually the one to change original dressing
| - If you note bleeding, reinforce the dressing and mark the area of bleeding
54
Drainage
- 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
Dressing Change
- 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
Montgomery Straps
- Used when frequent dressing changes are anticipated
| - Prevents skin irritation from tape removal
57
Surgical Drains
```
Penrose - Passive drainage onto dressing
Jackson Pratt (JP) - Non-mechanical vacuum bulb
Hemovac - Non-mechanical vacuum chamber
```
58
Hematomas
- Pooling of blood outside blood vessel
| - Develops when drainage blood accumulates under incision
59
Dehiscence
- 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
Evisceration
- Protrusion of abdominal organs from opened incision
| - Cover area with sterile dressing soaked in sterile saline and notify surgeon immediately
61
Fentanyl (Sublimaze, Duragesic)
- 100 times more potent than morphine.
| - Synthetic opioids like fentanyl are the most common drug involved in overdose deaths
62
Sublimaze (Parenteral)
- Used for severe pain
| - Used for moderate sedation
63
Duragesic (Transdermal)
- Patch activated by body heat
| - New patch over non-bony area every 72 hours
64
Transmucosal
```
- Absorbed across mucous membrane
Actiq - Lozenge on a stick
Onsolis - Buccal Film
Fentora - Buccal Tablet
Abstral - Sublingual Tablets
```
65
Meperidine (Demerol)
- No longer frequently used
- Significant toxic metabolite so use with caution
- Used for post-operative shivering
66
Methadone
- Used for treatment of pain and opioid addicts
67
Hydromorphone, Oxymorphone, Levorphanol
- Semi-synthetic opioid analgesic
- More potent than morphine but shorter duration
- Greater sedation
- Available in parenteral and oral forms
- Moderate to Severe Pain
68
Codeine
- 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
Oxycodone
- Long-acting analgesic
Roxicodone - Immediate release
OxyContin - Controlled release
70
Hydrocodone
- Most widely prescribed pain medication in the US
- Used in combination with aspirin, acetaminophen, ibuprofen
- Available as tablets, capsules, syrups
71
Tapentadol (Nucynta)
- Analgesic equivalent to oxycodone but causes less constipation
72
Agonist-Antagonist opioid
- Effective as analgesic with less potential abuse
73
Pentazocine (Talwin)
- Incomplete reversal of cardiovascular, respiratory, and behavioral depression induced by morphine
- 50 mg orally equates to analgesics of 60 mg of codeine
74
Nalbuphine (Nubain)
- Buturphanol
- Used during labor for pain
- 7 day patch or sublingual film (Suboxone)
75
Clinical Issues with Opioids
- 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
Naloxone (Narcan)
- 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
Non-Opioid Centrally Acting Analgesics
- Provide pain relief unrelated to opioid receptors
| - Do not cause respiratory depression, physical dependence, or abuse
78
Tramadol (ultram)
- 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
Clonidine (Duraclon)
- 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
Antiemetic and Prokinetic Medication
- 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
Metoclopramide
- Peripheral cholinergic agonist and dopamine antagonist
| - Most commonly used antiemetic/prokinetic drug
82
Prokinetic Drugs
- Improve esophageal and gastric motility
- Decrease gastric reflux
- Accelerate gastric emptying
- Limited to upper GI tract, esophagus, and stomach
