Care of Postop Pats Flashcards
Post anesthesia care unit (PACU)/Recovery Room purpose is: - most to this
Hand-off report (two-way verbal interaction)
Review Best Practice for Patient Safety and Quality Care
Overview of PACU and Hand-off Report
Sometimes go to ICU depending on surgery
Primary func is evaluate and stabilize pat - pats at risk for lot comps so need be closely monitored following surgery
ongoing evaluation and stabilization of patients
anticipate, prevent, and manage complications after surgery
Post anesthesia care unit (PACU)/Recovery Room purpose is: - most to this
Once at PACU anesthesologist/CRNA gives report - required to care for pats; pats could have comps easily
Report one most imp things do initially
Report between two health care professionals is required to communicate the patient’s condition and needs
Hand-off report (two-way verbal interaction)
Postoperative Hand-off Report
Review Best Practice for Patient Safety and Quality Care
History
Initial assessment data
Assessment in the PACU
ABCs - priority assessments esp if under gen anesthesia (highest risk for airway compromise)
Level of consciousness and awareness
Respiratory assessment is the most critical assessment to perform after surgery for any patient who has undergone general anesthesia or moderate sedation or has received sedative or opioid drugs - breathing, obstructions, adequate gas exchange
VS: Temperature, pulse, respiration, blood pressure
Oxygen saturation
Examine the surgical area for excessive bleeding and unusual drainage
Imp in handoff report - VS were and how looking in surgery - when extubated and blood loss to look for circ issue; imp for receiving nurse so adequately take care of pat
Initial assessment data
assess for patent airway and adequate gas exchange
Respiratory assessment is the most critical assessment to perform after surgery for any patient who has undergone general anesthesia or moderate sedation or has received sedative or opioid drugs - breathing, obstructions, adequate gas exchange
Always specific criteria - if go to unit or home; most facilities have tool or rating see if ready be transferred out and monitored less frequently
Health care team determines the patient’s readiness for discharge from the PACU
Recovery rating score may vary from facility to facility
Other criteria for discharge
May be discharged to a hospital unit (ICU, telemetry, medical-surgical) or home depending on level care needed
Discharge from the PACU
Stable vital signs
Normal body temperature
No overt/excessive bleeding
Able manage airway: Return of gag, cough, and swallow reflexes
Ability to take liquids - take something PO
Adequate urine output - void adequately
Other criteria for discharge
Primary funcs of PACU eval pats for possible comps so no comps of surgery and if are intervene to stop those and help prevent those
Respiratory - huge
Cardiovascular
Skin
Gastrointestinal
Neuromuscular
Kidney/Urinary issues
Gen potential comps of surgery
Atelectasis - IS, turn cough and deep breath to prevent this; high risk for resp comps such as pneumonia
Pneumonia
Pulmonary embolism (PE) - not moving around high risk DVTs which can move to lungs
Laryngeal edema - swelling esp neck surgery
Ventilator dependence - chronic pulm issues difficulty extubated and off breathing machine
Pulmonary edema
Respiratory - huge
Hypertension
Hypotension
Hypovolemic shock
Dysrhythmias - not uncommon postop esp if given anesthesia
Venous thromboembolism (VTE), especially deep vein thrombosis (DVT)
Heart failure - fluid circ
Sepsis
Disseminated intravascular coagulation (DIC) - excessive clotting and bleeding
Anemia - lot blood loss
Anaphylaxis
Cardiovascular
Pressure ulcers - risk factor in OR because intense pressure
Wound infection - monitor for infection because broke skin and primary defense
Wound dehiscence - incision opens and see subQ
Wound evisceration - through all layers and see organs; surgical emergency
Skin rashes or contact allergies - contact with anything in OR get contact dermatitis or irritation
Skin
Paralytic ileus - anesthesia affects smooth muscle innervation so anesthesia slows GI tract and when not up and moving bowels not working as well post up; when stop working is this; nonmechanical obstruction
Gastrointestinal ulcers and bleeding - could have this; check blood stools/dark stools
Gastrointestinal
Issue body term
Hypothermia
Hyperthermia
Cut into tissue want no - Nerve damage (check for sensation and movement); paralysis
Joint contractures
Neuromuscular
Affect smooth muscle and nerves that innervate the bladder
Urinary tract infection
Acute urinary retention - very common; watch output
Electrolyte imbalances - monitor H/H and these so in check
Acute kidney injury (AKI) - not often but can happen depending on surgery
Stone formation - not often but can happen depending on surgery
Kidney/Urinary issues
Out close monitory and to med-surg; not really sick; doing same thing as PACU but not as often
Airway (patent?)
Breathing (quality, pattern, rate, depth, accessory muscle use, oxygen, pulse oximetry, lung sounds)
Circulation
Mental status (level of consciousness or awareness) - early indicator of hypoxia
Surgical incision site (dressing, amount of drainage, bleeding, drains) - imp postop
T, P, BP (baseline, different from PACU?) - VS; imp know baseline so can catch comps
IV fluids (type, how much infused, rate, monitor intake) - if blood loss and how much fluid get and how much blood get
Other tubes (foley, NG, monitor output)
Pain assessment and management - always issue to stay on top of
Focused assessment on med-surg unit after discharge from PACU
Postoperative nausea and vomiting (PONV)
Decreased or no peristalsis for up to 24 hours
Paralytic ileus
Constipation
Managing pain is imp
Common rxns after surgery
Pretty common
Treatment via meds: Ondansetron (Zofran - common), Dimenhydrinate (Dramamine), Scopolamine - transdermal so not immediate
Postoperative nausea and vomiting (PONV)
Monitor bowel sounds, passage of flatus or stool - possibility paralytic ileus and slowing bowels; constipation/obstination; knows peristalisis returned
Decreased or no peristalsis for up to 24 hours
Electrolytes - risk for dysrhythmias so want make sure norm limits
CBC
ABG’s - very good indicator if resp issues which high risk for post up
Urinalysis
Creatinine - indices renal func; imp postop so kidneys working and able rid electrolytes and fluid volume
Other lab tests depend on the diagnosis, type of surgical procedure, and other health problems = specific ones for surgery
Laboratory assessment after surgery
Big deal esp if lost lot blood during surgery; H/H up and not trending down because may mean bleeding internally
BP and HR catchs bleeding early
Check WBC for infection
Changes in electrolytes, hematocrit, and hemoglobin levels often occur during the first 24 to 48 hours because of blood and fluid loss and the body’s reaction to the surgical process
Increase in the band cells (immature neutrophils) in the white blood cell differential count, may indicate an infection; known as a “left-shift” or bandemia - increase immature WBCs - indicate infection going on
CBC
Need monitor and interventions to prevent
Potential for hypoxemia - airway management, gas exchange
Potential for wound infection and delayed healing
Acute pain
Priority patient probs after surgery
related to the effects of anesthesia, pain/pain meds, opioid analgesics, and immobility - impaired gas exchange so hypoxemia is a risk; immobile - risk for atelectasis - risk for hypoxemia
Potential for hypoxemia - airway management, gas exchange
related to wound location, decreased mobility, drains and drainage, and tubes and checking dressings
Potential for wound infection and delayed healing
related to the surgical incision, positioning during surgery, and endotracheal (ET) tube irritation
Stay on top of this
Acute pain
Airway maintenance - not able extubated make sure not; make sure gag reflex returned; able handle secretions and decent cough to clear secretions; imp things to monitor for
Monitor oxygen saturation (check oxygenated well), pulse oximetry
Positioning - getting up as early as possible; good for lungs; prevents resp comps; if cannot reposition
Oxygen therapy, if indicated
Breathing exercises
Movement/Mobility
Preventing hypoxemia for postop
Splint incision, cough, deep breathe, use incentive spirometer - deep breathing so prevent atelectasis and pneumonia; issues with pain when breathing so splint - less pain when breathing; brace with blanket/pillow so still take deep breaths
Breathing exercises
Encourage early ambulation
If the patient is on bed rest, reposition every 2 hours, perform breathing and leg exercises
Antiembolism stockings
Pneumatic compression devices - SCDs
Movement/Mobility
Dressing change
Assess wound for infection
Assess drains if placed
Drug therapy (antibiotics) - not uncommon pre and intraop and maybe postop
Preventing wound infection and delayed healing
Surgeon will change first dressing postop
Dressing change
if oozing and seeping through dressing reinforce the dressing if needed - lot output mark it to monitor it to see if worsening esp if blood
After that we do dressing changes as told (sterile do sterile)
Surgeon will change first dressing postop
warmth, swelling, tenderness or pain/red - indications possible infection; documenting and assessing document all of that
type and amount of drainage - document this if present
Assess wound for infection
Irrigate if required
Patency - make sure and wound should stay patent and how looks
amount, color, and type of drainage
Assess drains if placed
Dehiscence
Evisceration
Wound comps
partial or complete separation of the outer wound layers, sometimes described as a “splitting open of the wound”
Not that uncommon
Wound that opens up; much higher risk if abdominal because increased pressure
Apply a sterile nonadherent (e.g., Telfa) or sometimes saline dressing to the wound
Notify the surgeon and put sterile dressing on it
Instruct patient to lie supine, bend the knees - help keep dehiscening more, avoid coughing; not increase intraabdominal pressure with coughing
Dehiscence –
total separation of all wound layers all through subQ and protrusion of internal organs through the open wound
Surgical emergency-prepare for surgery because going right away
Notify the surgeon immediately
Apply sterile saline soaked gauze
Instruct patient to lie supine, bend knees, avoid coughing - not do anything to increase pressure; do not leave pat
Review Emergency Care of the Patient with Surgical Wound Evisceration
Evisceration –
Offer alternative therapies for relaxation, pain reduction, and distraction, such as positioning, massage, relaxation techniques, and diversion
Drug therapy - big thing
Managing pain
Splinting - holding pressure on incision so when cough and deep breathe not putting pressure on incision
Assess the patient’s comfort level and the effectiveness of therapies
Offer alternative therapies for relaxation, pain reduction, and distraction, such as positioning, massage, relaxation techniques, and diversion
Opioid analgesics (often times given around surgical procedures) are given during first 24 to 48 hours after surgery - within day-two control with other types meds
Around-the-clock or patient-controlled analgesia (PCA) - pump hooked up to and press button every 15 minutes to admin own pain med- highly locked up and secure and nurses monitoring that; if can use PCA have better pain control use less pain med and deal pain quicker because not relying on nurse; very common and lots comps - such as depression but good thing to use immediate postop
Assess the type, location, and intensity of the pain before and after giving medication - frequent pain assessments
Commonly used medications - opioid: Morphine Sulfate - opioid, Hydromorphone (Dilaudid) - high pain tolerance, Ketorolac (Toradol) - high ibuprofen (ibuprofen not given because of bleeding), Codiene, Butorphanol (Stadol), Oxycodone with aspirin (Percodan) - opioid or Oxycodone with acetaminophen (Tylox, Percocet) - opioid
Drug therapy - big thing
discharge postop - detailed info about what need do and follow-up
When call provider and when follow-up
Prevention of infection
Care and assessment of the surgical wound - special care
Management of drains and catheters - big
Nutrition therapy - limitations on diet
Pain management - pain control
Drug therapy - antibiotics, anticoags, whatever drug regiment is
Progressive increase in activity - activity limitation know when get full shower and bath
Individualized
See what support have and if able care for self at home and may be temp and need assess needs at home and able adequately care for themselves
Appropriate referrals, if needed
Follow-up with the surgeon
Patient teaching on discharge
