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Surgical Patient > Care Of Post Operative Patient > Flashcards

Care Of Post Operative Patient Flashcards

0
Q

Receiving patient from PACU

A

PACU nurse gives verbal report, first priority is to take vitals and compare to baseline, assessment and management of complications

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1
Q

1 goal of post op patient?

A

Healing and recovery, prevent complications

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2
Q

Post op complications:

A

Pain, exhaustion, immobility, reaction to medications, loss of control, and exposure.

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3
Q

Potential alteration in resp function:

A

Assess: airway patency, position patient in Sims or semi-prone with HOB elevated > 30 degrees, evaluate chest symmetry, RR, depth, character,

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4
Q

Most common cause of obstruction:

A

Tongue

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5
Q

First sign of respiratory problem

A

Restlessness ( ^ RR\HR, decrease in BP sign of internal bleeding)

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6
Q

Respiratory complications:

A

Atelectasis, pneumonia, and aspiration pneumonia

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7
Q

Atelectasis

A

Alveolar collapse causes airless condition of the lung, causes: hypoventilation, prolonged BR, ineffective cough, anesthesia, intubation, S/S: pain, tachypnea, dyspnea, tachycardia, fever, low SPO2

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8
Q

Pneumonia:

A

Inflammation/infection of the lungs, most common cause of resp problem in the elderly, obese, malnourished, COPD, S/S: fever, dyspnea, pain, productive cough

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9
Q

Aspiration pneumonia:

A

Inhalation of gastric contents, toxic to lung tissue b/c very acidic

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10
Q

Nursing management of resp complications:

A

Deep breathing and coughing, early ambulation, IS

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11
Q

Deep berthing and coughing:

A

Begin as soon as responsive, turn(q 2h) cough (4-6 deep breaths then forceful cough q1h)

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12
Q

Incentive spirometer:

A

Maximize lung expansion, 10 deep breaths/hr

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13
Q

Early ambulation:

A

Most important intervention to prevent post-op complications, ^ vital capacity of lungs, ( ^ HR, perfusion, and RR)

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14
Q

Maintenance of adequate resp function is to:

A

Prevent complications

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15
Q

Potential alterations in CV function:

A

Fluid and electrolyte imbalances post op contribute to CV alteration, fluid status directly affects cardiac output ( making heart work harder caused by dec. in O2 and fluid volume), assessment (VS, skin color, temp., arrhythmias, pulse deficits)

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16
Q

CV complications:

A

DVT (edema, erythema, warm/hot, venostasis), thrombophlebitis (inflammation with clot), and embolus (clot dislodges and travels) * risk due to increased platelet production as body reacts to stress of sx and legs due to inactivity*

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17
Q

CV interventions:

A

Early ambulation, SCDs/TEDs, leg exercises

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18
Q

If thrombus occurs:

A

Venous duplex, bed rest, do not message legs!, anti-coagulant med.

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19
Q

Pulmonary embolus

A

Clott lodged in pulmonary circulation (blocks blood supply to lower lobe), S/S: restlessness, dyspnea, tachypnea, sudden sharp cp, crackles, change in mental status (hypoxia), size of emboli reflects results (death), report and S/S to MD immediately

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20
Q

Syncope

A

Brief lapse in consciousness caused by transient cerebral hypoxia (postural hypoxia, vascular pooling, sudden changes in position)

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21
Q

Interventions for syncope

A

Change position slowly, raise HOB, progress to sitting, dangle, to stand, monitor HR, safety for fall prevention. * if patient faints, assist to the floor to prevent injury*

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22
Q

Fluid and electrolyte imbalance:

A

Normal response to sx (fluid retention 2-5 days post op-protective measure to maintain BP and volume), accurate I&O, monitor lab work (Ca, Na, K, Cl, BUN, creatinine), watch for dehydration (thirst a late sign)

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23
Q

Fluid deficit:

A

Slow or inadequate fluid replacement, (vomiting bleeding, or drainage)

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24
Q

Hypokalemia:

A

Results from urinary and GI losses, vomiting, or diarrhea. Fluid & Na retention > K excretion, sx stress causes K loss & excretion, if K not replaced by IV (20-40 mEq/daily), = hypokalemia, S/S: muscle weakness, irritability, weakness, confusion, arrhythmias

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25
Q

Management of hypokalemia:

A

Accurate I&O, monitor labs, IV management, assess for K OD (paralysis, confusion, arrhythmias) incorrect K levels can cause death!!

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26
Q

Urinary complications:

A

30 ml/hr first void = approximately 200 ml, spinal anesthesia, must void >50 ml before discharge, regular voiding by 6-8 hrs post op

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27
Q

Urinary retention:

A

Expect low output for 1st 24 hrs (800-1500 ml/day fluid balance has to stabilize) nurse management: early ambulation, assess for bladder distension, normal position to void if possible, provide privacy, if no void/ notify MD

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28
Q

UTI:

A

Related to urinary stasis, retention, or in dwelling catheters. Assess: character, dysuria, odor, fever, WBCs, remove catheter ASAP to prevent infection

29
Q

Acute renal failure:

A

Rapid decline of kidney function (related to trauma from sx or decreased perfusion), decreased urinary output, elevated labs ( develops over hrs or days), can be reversed = important to maintain homeostasis while kidneys are healing

30
Q

GI complications:

A

Decreased peristalsis for 24 hrs post abd sx, (3-4 days), assessment: distension, bowel sounds, flatus may be first sign of bowel function, early ambulation increases peristalsis

31
Q

Nausea and vomiting:

A

Results from anesthesia and narcotics, decreased peristalsis, bowel sounds must be present before beginning fluids

32
Q

Abdominal distension:

A

Decreased peristalsis, swallowed air and GI secretions accumulate in colon producing flatulence and pain. Large bowel/ 3-5 days; sm bowel/ 24 hrs * gas pains may be worse 2nd or 3rd day post op, when bowel function begins to return

33
Q

Paralytic ileus:

A

Temporary paralysis of the bowel, cause by manipulation of sx, S/S: pain abd. Distension, nausea, vomiting, auscultation for bowel sounds, bowel rest (NPO, NGT)

34
Q

Singultus:

A

Hiccups! Intermittent spasms of diaphragm, caused by irritation of phrenic nerve, Thorazine to tx

35
Q

Palatitis:

A

Inflammation of soft palate, related to intubation, infection, trauma to soft palate, prevent further irritation (warm salt water swish/spit)

36
Q

Integumentary complications:

A

Largest organ of the body-1st line o defense against bacterial invasion, sensory organ,

37
Q

Integumentary classification according too:

A

Status of skin, cause of wound, severity of tissue injury, cleanliness of wound

38
Q

Types of wounds:

A

Incision, laceration, abrasion, contusion, puncture, fracture

39
Q

Incision:

A

Wound in which each tissue layer is cut and separated smoothly by sharp-bladed instruments, margins are regular/even, nearby tissues undamaged

40
Q

Laceration:

A

Irregular tear in tissue layers, ragged edges, not clean, high risk of infection

41
Q

Abrasion:

A

Scraping away of portion of skin or mm as a result of injury or mechanical means (trauma), not through all layers (superficial)

42
Q

Contusion:

A

Injury to tissue where skin is not broken, soft tissue trauma, ecchymosis (bruise)

43
Q

Puncture or stab:

A

Wound made by sharp instrument, intentional/unintentional, high risk of infection

44
Q

Fracture:

A

Puncturing or tearing of tissue from inside by broken bone

45
Q

Wound assessment:

A

Drainage, hemorrhage, odor, proximity of edges, cleanliness of wound, length and depth of wound, surrounding tissue, drains?, erythema/edema, pain, sensory perception distal to injury

46
Q

Objectives of wound care:

A

Promote hemostasis, prevent infection, prevent further injury, support healing process, promote return to normal function.

47
Q

Phases of wound healing:

A

Primary intention: when wound edges are nearly approximated, secondary intention: edges not neatly approximated, tertiary intention: very long time to heal

48
Q

Wound drainage:

A

Exudate: serous- clear, watery plasma, sanguineous- bloody, serosanguineous- combo of blood and plasma, purulent- thick, infected/ type of organism determines color ( yellow, green, brown)

49
Q

Wound hemorrhage:

A

most common 1st 48 hrs post op assess amount, number of drsgs, reinforce prn, circle/date/time/, check under patient for drainage, S/S: restlessness, pale, cold, clammy, vs change (BP,HR,RR)

50
Q

Primary intention phase of wound healing:

A

Initial- 3-5 days, granulation- 5days- 4 wks, maturation- scar is formed

51
Q

Secondary intention wound healing:

A

Heal from bottom up, may need debridement,

52
Q

Tertiary intention wound healing:

A

Delayed suturing of wound, left open for infection to clear, results in delayed healing and larger/bigger scar

53
Q

Complications of wound healing:

A

Hemorrhage (internal/external), infection, dehiscence, evisceration, keloids/hypertrophic scars

54
Q

Keloid or hypertrophic scar:

A

african American, genetic/hereditary excess production of collagen tissue, scar enlarges beyond boundaries of incision

55
Q

Evisceration:

A

Wound edges separate and abd contents protrude outside of body. EMERGENCY !! Notify MD ASAP, keep patient calm, position in low fowlers with knees flexed (decreases pressure on abd), put on sterile gloves, sterile towels soaked in sterile NSS over contents (prevent drying out), monitor vs

56
Q

Wound dressing products:

A

Gauze, impregnated non-adherent dressings, transparent adhesive films, hydrocolloids, and hydrogels

57
Q

Gauze dressing:

A

Permits drainage from wound/ allows air to get to wound, need to know purpose (debridement, remove slowly, if not for debridement, soak with ns to remove)

58
Q

Impregnated non-adherent dressings:

A

Material impregnated with petroleum, saline, zinc, antimicrobials, or other agents, prevents drying of tissue to promote healing, and requires secondary drsg to secure in place

59
Q

Transparent adhesive films:

A

Adhesive, plastic, non-absorbent drsg, allows exchange of oxygen, impermeable to water and bacteria, promotes moist environment for wound that speeds epithelial growth, and allows visualization of wound.

60
Q

Hydrocolloids:

A

Waterproof adhesive wafer, paste, or powder. Drsg wafer has two layers: inner and outer. Absorbs exudate, produces moist environment for healing, can be worn for <7 days, conforms to wound. When removing, gel separated and stays with wound, preventing damage to new tissue. Gel looks like pus when drsg removed (irritate with NS before assessing)

61
Q

Hydrogels:

A

Glycerin or water based non-adhesive jellylike sheets, granules, or gels. Oxygen can permeate, needs cover drsg. Liquifies necrotic tissue, hydrates wound, fills in dead spaces, and environment from wound contaminates.

62
Q

Types of dressings:

A

Dry sterile and wet to dry

63
Q

Dry sterile dressing:

A

Protects wound from environment contaminates and environment from wound contaminates. Surgical drsg (3 layers) - primary/absorbent/outer

64
Q

Wet to dry:

A

For debridement, process: dries to wound surface in between changes, necrotic debris softened by solution and adheres to mesh gauze as it dries, debris removed as drsg removed.

65
Q

Wound irrigation:

A

Must have MD order, cleanse skin first, DO NOT use hydrogen peroxide, using blunt tip syringe thoroughly irrigate wound using gentle pressure

66
Q

Bandages:

A

Length of material applied to fit smaller parts of the body.

67
Q

Binder:

A

Provides support for internal an external organs. Thoracic/abd areas, secure drsg, minimize incision discomfort.

68
Q

Discharge planning an F/U care:

A

On admission/on going process, gives patient awareness, facilitates self care responsibilities, case management consult, average LOS = 24 hrs - 5 days

69
Q

Discharge planning includes:

A

Wound care, medications, activities, nutrition, and what to report to MD

Surgical Patient (5 decks)

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