Ch 19 postoperative

Question 1

immediately after surgery and continues until the patient is discharged from medical care

Answer 1

postoperative period begins

Question 2

in a postanesthesia care unit (PACU)

Answer 2

patient’s immediate recovery period is managed

Question 3

the anesthesia care provider (ACP), OR nurse, and PACU nurse.

Answer 3

patient’s admission to the PACU is a joint effort among

Question 4

postanesthesia care

Answer 4

3 phases of

Question 5

their condition and the type of anesthesia they received.

Answer 5

patients move through the phases of care is determined by

Question 6

is stable and recovering well, the patient may rapidly progress through Phase I to either Phase II care or an inpatient unit.

Answer 6

Phase I care on admission to the PACU

Question 7

accelerated progress is called rapid postanesthesia care unit progression (RPP)

Answer 7

(in phase 1) patient may rapidly progress through Phase I to either Phase II care or an inpatient unit AKA

Question 8

which involves admitting ambulatory surgery patients directly to Phase II care.

Answer 8

Another accelerated system of care is fast-tracking,

Question 9

• Care during the immediate postanesthesia period
• ECG and more intense monitoring (e.g., arterial BP monitoring, mechanical ventilation)
Goal: Prepare patient for transfer to Phase II level of care, an inpatient unit, or intensive care setting

Answer 9

Phase I

Question 10

• Ambulatory surgery patients
• Fast-tracking (i.e., patients who have bypassed Phase I level of care)
-Goal: Prepare patient for transfer to extended observation, home, or extended care facility
-Extended Observation
• Extended care or observation after transfer/discharge from Phase I or Phase II levels of care
-Goal: Prepare patient for self-care

Answer 10

Phase II

Question 11

• Various levels of care offered in the same environment

Answer 11

Blended Levels of Care

Question 12

detect respiratory depression in high-risk patients.

Answer 12

transcutaneous carbon dioxide (PtcCO2) and end-tidal CO2(PetCO2) (capnography) monitoring are used to

Question 13

can help you detect respiratory distress early

Answer 13

Volumetric capnography and acoustic respiratory rate monitoring

Question 14

explain all activities to the patient from the time of admission to the PACU.

Answer 14

hearing is the first sense to return in the unconscious patient,

Question 15

sensory and motor blockade may still be present and you should assess dermatome levels

Answer 15

patient received a regional anesthetic (e.g., spinal, epidural),

Question 16

sensory and motor function first returns distal to the site where the anesthetic was given. This means the areas near the site of injections are the last to recover.

Answer 16

recovery from regional anesthesia,

Question 17

In the immediate postanesthesia period the most common causes of airway compromise include obstruction, hypoxemia, and hypoventilation

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(postanesthesia) most common causes of airway compromise include

Question 18

(1) have had general anesthesia; (2) are older than 55 years of age; (3) have a history of tobacco use; (4) have preexisting lung disease and/or sleep-disordered breathing; (5) are obese; (6) have co-morbidities (e.g., renal disease, diabetes, hypertension); or (7) have undergone airway, thoracic, or abdominal surgery.

Answer 18

Patients at high risk include those who

Question 19

and in the immediate postoperative period. High-risk patients should be monitored in a critical care or postanesthesia care unit.

Answer 19

Pulmonary complications pose the greatest risk to patients in the postanesthesia period

Question 20

is often caused by the patient’s tongue blocking the airway

Answer 20

Airway obstruction

Question 21

base of the tongue falls backward against the soft palate and occludes the pharynx. It is most pronounced in the supine position and in the patient who is extremely sleepy after surgery.

Answer 21

Airway obstruction pathophysiology

Question 22

, a partial pressure of arterial oxygen (PaO2) less than 60 mm Hg, is characterized by a variety of nonspecific clinical signs and symptoms, ranging from agitation to somnolence, hypertension to hypotension, and tachycardia to bradycardia. Pulse oximetry will show low O2 saturation (less than 92%).

Answer 22

Hypoxemia

Question 23

is atelectasis

Answer 23

most common cause of hypoxemia after surgery

Question 24

may be the result of bronchial obstruction caused by retained secretions, decreased respiratory excursion, or general anesthesia.

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Atelectasis (alveolar collapse)

Question 25

when mucus blocks bronchioles or there is not enough alveolar surfactant (substance that holds the alveoli open)

Answer 25

Atelectasis occurs

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include pulmonary edema, pulmonary embolism (PE), aspiration, and bronchospasm.

Answer 26

Other causes of hypoxemia

Question 27

fluid overload, heart failure, prolonged airway obstruction, sepsis, or aspiration.

Answer 27

pulmonary edema. It may be the caused by

Question 28

of gastric contents into the lungs.

Answer 28

After surgery patients are at risk for aspiration

Question 29

anesthesia depresses the respiratory protective airway reflexes. Gastric aspiration is a potentially serious emergency. It may result in laryngospasm, pneumonia, and pulmonary edema

Answer 29

risk for aspiration of gastric contents into the lungs. This can occur because

Question 30

is the result of an increase in bronchial smooth muscle tone with resulting closure of small airways.

Answer 30

Bronchospasm

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Airway edema develops, causing secretions to build up in the airway. The patient will have wheezing, dyspnea, use of accessory muscles, hypoxemia, and tachypnea.

Answer 31

Bronchospasm results

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aspiration, endotracheal intubation, pharyngeal suctioning, or an allergic response.

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Bronchospasm may be due to

Question 33

more often in patients with a history of smoking, asthma, and chronic obstructive pulmonary disease (COPD).

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Bronchospasm occurs with ppl having history of

Question 34

,, is characterized by a decreased respiratory rate or effort, hypoxemia, and increasing hypercapnia (increasing PaCO2).

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Hypoventilation( a common complication in the PACU)

Question 35

result from depression of the central respiratory drive (from anesthesia or use of opioids), poor respiratory muscle tone (from neuromuscular blockade or disease), or a combination ofboth.

Answer 35

Hypoventilation may result from

Question 36

are atelectasis and pneumonia, especially in patients with co-morbidities (e.g., OSA, COPD, heart failure) and after abdominal and thoracic surgery

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Common causes of respiratory problems

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hypoventilation, immobility and bed rest, ineffective coughing, and history of tobacco use.

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development of mucous plugs and decreased surfactant production is directly related to

Question 38

the respiratory passages have been irritated by heavy smoking, COPD, pulmonary infection, or dry mucous membranes that occurs with intubation, inhalation anesthesia, and dehydration.

Answer 38

Increased bronchial secretions occur when

Question 39

pneumonia.

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Without intervention, atelectasis can progress to

Question 40

Allergic drug reaction

Mechanical irritation from intubation

Fluid overload

Answer 40

Laryngeal edema (airway obstruction)

Question 41

Irritation from endotracheal tube, anesthetic gases, or gastric aspiration

Most likely to occur after removal of endotracheal tube

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Laryngospasm

Question 42

Secretion stimulation by anesthetic agents
Dehydration of secretions

Answer 42

Retained thick secretions

Question 43

Muscular flaccidity associated with ↓ consciousness and muscle relaxants

Answer 43

Tongue falling back

Question 44

Inhalation of gastric contents into lungs

Answer 44

Aspiration (hypoxemia)

Question 45

Bronchial obstruction caused by retained secretions or ↓ lung volumes

Answer 45

Atelectasis (hypoxemia)

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↑ Smooth muscle tone with closure of small airways

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Bronchospasm (hypoxemia)

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Fluid overload

↑ Hydrostatic pressure

↓ Interstitial pressure

↑ Capillary permeability

Answer 47

Pulmonary edema (hypoxemia)

Question 48

Thrombus dislodged from peripheral venous system and lodged in pulmonary arterial system

Answer 48

Pulmonary embolism (hypoxemia)

Question 49

Medullary depression from anesthetics, opioids, sedatives

Answer 49

Depressed central respiratory drive (Hypoventilation)

Question 50

Tight casts, dressings, abdominal binders

Positioning and obesity preventing lung expansion

Answer 50

Mechanical restriction (Hypoventilation)

Question 51

Shallow breathing to prevent incisional pain

Answer 51

Pain

Question 52

Neuromuscular blockade

Neuromuscular disease

Answer 52

Poor respiratory muscle tone

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is normally colorless and thin in consistency.

Answer 53

Mucus from the trachea and throat

Question 54

normally thick with a pale, yellow tinge

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Sputum from the lungs and bronchi is

Question 55

a respiratory infection.

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Changes in sputum (e.g., color) may indicate

Question 56

Position the unconscious patient in a lateral “recovery” position

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Postoperative Patient Positioning

Question 57

position maximizes expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm.

Answer 57

Once conscious, place the patient in a supine position with the head of the bed elevated

Question 58

, deep breathing, coughing, and use of an incentive spirometer help prevent alveolar collapse and move respiratory secretions to larger airway passages for expectoration

Answer 58

Once the patient is more awake

Question 59

requires the patient to inhale as deeply as possible and, at the peak of inspiration, hold the breath for a few seconds, and then exhale. This is followed by another deep breath and cough.

Answer 59

sustained maximal inspiration,

Question 60

helps by giving visual feedback of respiratory effort

Answer 60

use of an incentive spirometer

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involves inhaling slowly and deeply through the nose, holding the breath for a few seconds, and then exhaling slowly and completely through the mouth.

Answer 61

Diaphragmatic or abdominal breathing

Question 62

is essential in mobilizing secretions

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Effective coughing

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and stimulates the cough reflex. Splinting an abdominal incision with a pillow or a rolled blanket supports the incision and aids in coughing and expectorating secretions

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If secretions are in the respiratory tract, deep breathing often moves them up

Question 64

hypotension, hypertension, and dysrhythmias

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most common cardiovascular problems include

Question 65

those with altered respiratory function, those with a history of cardiovascular disease, older adults, the debilitated, and the critically ill.

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patients at greatest risk for altered cardiovascular function include

Question 66

can cause hypoperfusion to the vital organs, especially the brain, heart, and kidneys

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Hypotension

Question 67

of disorientation, loss of consciousness, chest pain, and oliguria reflect hypoperfusion, hypoxemia, and the loss of physiologic compensation

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Clinical signs Hypotension

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is fluid and blood loss, which may lead to hypovolemic shock.

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most common cause of hypotension in the PACU

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in myocardial infarction, cardiac tamponade, or PE, results in an acute drop in cardiac output

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Primary heart dysfunction, which may occur

Question 70

of the negative chronotropic (rate of heart contraction) and negative inotropic (force of heart contraction) effects of drugs, such as β-adrenergic blockers, digoxin, or opioids. Other causes of hypotension include decreased systemic vascular resistance and dysrhythmias.

Answer 70

Secondary heart dysfunction occurs because

Question 71

from sympathetic nervous system stimulation. This may be the result of pain, anxiety, bladder distention, or respiratory distress. Hypertension may be related to hypothermia and preexisting hypertension.

Answer 71

Hypertension most often occurs

Question 72

hypoxemia, hypercapnia, electrolyte and acid-base imbalances, circulatory instability, preexisting heart disease, hypothermia, pain, surgical stress, and many anesthetic agents.

Answer 72

Many problems can cause dysrhythmias. These include

Question 73

. Such imbalances may result from a combination of the body’s normal response to the stress of surgery, excessive fluid losses, and IV fluid replacement. The body’s fluid status directly affects cardiac output.

Answer 73

On the clinical unit, postoperative fluid and electrolyte imbalances are contributing factors to heart problems

Question 74

, which maintains both blood volume and BP

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Fluid retention during postoperative days 1 to 3 can result from the stress response

Question 75

and adrenocorticotropic hormone (ACTH) and activation of the renin-angiotensin-aldosterone system (RAAS)

Answer 75

Fluid retention results from the release of antidiuretic hormone (ADH)

Question 76

the adrenal cortex to secrete cortisol and, to a lesser degree, aldosterone

Answer 76

ACTH stimulates

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and causing marked release of aldosterone. Both mechanisms that increase aldosterone lead to significant sodium and fluid retention, thus increasing blood volume.

Answer 77

Fluid losses resulting from surgery decrease kidney perfusion, stimulating the RAAS

Question 78

when chronic disease (e.g., heart, kidney) exists, or when the patient is an older adult.

Answer 78

Fluid overload may occur during this period of fluid retention if we infuse IV fluids too rapidly,

Question 79

blood loss during surgery, or slow or inadequate fluid replacement can decrease cardiac output and tissue perfusion. Losses from vomiting, bleeding, wound drainage, or suctioning can contribute to fluid deficits.

Answer 79

Fluid deficits from untreated preoperative dehydration,

Question 80

can result from urinary and gastrointestinal (GI) tract losses.

Answer 80

Hypokalemia

Question 81

the heart’s contractility and may contribute to decreases in cardiac output and tissue perfusion.

Answer 81

Low serum potassium levels directly affect

Question 82

urine output of at least 0.5 mL/kg/hr and a normal serum creatinine are considered

Answer 82

indicative of adequate renal function.

Question 83

increasing platelet production

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stress response contributes to an increase in clotting tendencies by

Question 84

may form in leg veins because of venous stasis, vein injury, or a hypercoagulable state.

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venous thromboembolism (VTE)

Question 85

older adults, obese persons, immobilized patients, and patients with a history of PE or predisposition to clotting.

Answer 85

VTE is especially common in

Question 86

tachypnea, chest pain, hypotension, agitation, tachycardia, and dyspnea, especially when the patient is already receiving O2 therapy.

Answer 86

PE in any patient with

Question 87

is an uncomfortable but less serious complication. It may develop in a leg vein because of venous stasis or in the arm veins because of irritation from IV catheters or solutions.

Answer 87

Superficial thrombophlebitis

Question 88

from decreased cardiac output, fluid deficits, or defects in cerebral perfusion

Answer 88

Syncope (fainting) may result

Question 89

when the patient ambulates. It is more common in the older adult or in the patient who has been immobile for long periods

Answer 89

Syncope often occurs because of postural hypotension

Question 90

with sympathetic nervous system stimulation. This produces vasoconstriction and maintains BP.

Answer 90

when the patient stands up quickly, the arterial baroreceptors respond to the accompanying fall in BP

Question 91

immobile, or postanesthesia patient.

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sympathetic and vasomotor functions may be diminished in the older adult,

Question 92

, or more often until stabilized and then less often in Phase II.

Answer 92

Plan to obtain vital signs every 15 minutes in Phase I

Question 93

pink skin is usually from the residual vasodilating effects of anesthesia and suggests only a need for continued observation.

Answer 93

Hypotension accompanied by a normal pulse and warm, dry,

Question 94

to promote oxygenation of hypoperfused organ

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Begin treatment of hypotension with O2 therapy

Question 95

fluid loss, give IV fluid boluses to normalize BP

Answer 95

Because the most common cause of hypotension is

Question 96

vasoconstrictive drugs to increase systemic vascular resistance.

Answer 96

Peripheral vasodilation and hypotension may require

Question 97

may include giving analgesics, assisting with voiding, and correcting respiratory problems. Rewarming corrects hypothermia-induced hypertension. The patient with preexisting hypertension or who has undergone heart or vascular surgery usually needs drug therapy to reduce BP.

Answer 97

Treatment of hypertension centers on removing the cause of sympathetic nervous system stimulation.

Question 98

(1) increases muscle tone; (2) stimulates circulation, which prevents venous stasis and VTE, and speeds wound healing; and (3) increases vital capacity and supports normal respiratory function.

Answer 98

Early ambulation is the most significant general nursing measure to prevent complications. The exercise associated with walking

Question 99

is a short-term neurologic change manifested by behaviors such as restlessness, agitation, disorientation, thrashing, and shouting.

Answer 99

Postoperatively, emergence delirium

Question 100

anesthetic agents, bladder distention, pain, long duration of preoperative fasting, residual neuromuscular blockade, or the presence of an endotracheal tube.

Answer 100

delirium occurs, first suspect hypoxia. Other causes include

Question 101

This includes anesthetic agents as well as drugs used during the perioperative period. Contributory nonpharmacologic causes include metabolic disorders, electrolyte imbalances, hypertension, liver disease, uremia, central anticholinergic syndrome, and hypothyroidism. Other causes can include hypoxia, hypercapnia, hemorrhage, and embolism.

Answer 101

most common cause of delayed emergence (failure to regain consciousness 30-60 mins after general anaesthesia) after anesthesia is drug-related.

Question 102

postoperative cognitive dysfunction (POCD) and delirium.

Answer 102

Two types of cognitive impairments seen in surgical patients are

Question 103

(e.g., memory, ability to concentrate) for weeks or months after surgery
- primarily in the older surgical patient

Answer 103

POCD is a decline in the patient’s cognitive function

Question 104

preexisting cognitive impairment, duration of anesthesia, complications during surgery, and infection contribute to the

Answer 104

causes of (POCD)postoperative cognitive dysfunction

Question 105

severe pain, fluid and electrolyte imbalances, hypoxemia, drug effects, sleep deprivation, and sensory deprivation or overload.

Answer 105

delirium may be the result of

Question 106

Signs include cognitive dysfunction, varying levels of consciousness, altered psychomotor activity, and a disturbed sleep/wake cycle

Answer 106

Delirium sign and symptoms

Question 107

results from the patient undergoing alcohol withdrawal

Answer 107

Alcohol withdrawal delirium

Question 108

characterized by restlessness, insomnia, nightmares, irritability, and auditory or visual hallucinations

Answer 108

Alcohol withdrawal delirium

Question 109

is hypoxemia

Answer 109

most common cause of agitation in the PACU

Question 110

is prolonged drug action, delays in awakening usually spontaneously resolve with time. If necessary, antagonists can reverse the effects of benzodiazepines and opioids.

Answer 110

most common cause of delayed emergence

Question 111

The incision and retraction during surgery traumatize the skin and underlying tissues.

Answer 111

pain is caused by the interaction of several physiologic and psychologic factors.

Question 112

patient does not feel pain when the internal viscera are cut. Pain, does, however, come from pressure in the internal viscera.

Answer 112

pain comes from viscera

Question 113

intestinal distention, bleeding, or abscess formation. Pain increases the risk for atelectasis and impaired respiratory function.

Answer 113

deep visceral pain may signal a complication such as

Question 114

restlessness, grimacing, changes in vital signs

Answer 114

indications of pt pain if can’t speak

Question 115

the use of single modalities (e.g., opioid drugs, PCA, regional analgesic [local anesthetic infiltration]), or multimodal analgesia

Answer 115

Pain control techniques include

Question 116

, or the use of 2 or more analgesics with different mechanisms of action (e.g., an opioid and a nonsteroidal antiinflammatory drug [NSAID]), is recommended.

Answer 116

Multimodal analgesia

Question 117

reduces pain, opioid use, and opioid-related adverse effects.

Answer 117

Multimodal analgesia

Question 118

most common include constipation, nausea and vomiting, respiratory and cough depression, and hypotension.

Answer 118

pain med side effects

Question 119

allows the self-administration of predetermined doses of analgesia by the patient.

Answer 119

Patient-controlled analgesia (PCA)

Question 120

and may offer advantages over the IV route (e.g., needleless, low infection risk, decreased drug errors associated with pump malfunction or inaccurate programming).

Answer 120

transdermal route is for short-term pain management

Question 121

are early ambulation, better pain management than with as-needed analgesia, and greater patient satisfaction

Answer 121

Some advantages of PCA

Question 122

is the infusion of opioid analgesics through a catheter placed into the epidural space surrounding the spinal cord.

Answer 122

Epidural analgesia

Question 123

intermittent bolus dosing, continuous infusion, and epidural PCA

Answer 123

Administration methods of epidural analgesia include

Question 124

the infiltration of a nonopioid drug into the surgical site, is another way to manage postoperative pain. A disposable or mechanical infusion pump delivers the local anesthetic via a catheter directly to the surgical incision site. A single dose of bupivacaine liposome injectable suspension (Exparel) provides pain relief with reduced opioid needs for up to 72 hours.

Answer 124

Perineural local anesthesia,

Question 125

Complementary and alternative therapies such as music therapy, guided imagery, relaxation exercises, and aromatherapy are effective adjuncts in pain management. Nondrug approaches such as repositioning, massage, and distraction can enhance pain management.

Answer 125

Nondrug approaches pain management

Question 126

is a core body temperature less than 96.8°F (36°C)

Answer 126

Perioperative hypothermia

Question 127

when heat loss exceeds heat production. Heat loss may occur due to skin exposure, use of cold irrigants, skin preparations, and unwarmed inhaled gases.

Answer 127

Hypothermia occurs

Question 128

those with systolic BP less than 140 mm Hg, older patients, female patients, and patients who receive epidural or spinal anesthesia are at a higher risk.

Answer 128

Risk factors for hypothermia

Question 129

Long surgical procedures, open cavity procedures (e.g., abdominal or thoracic) and prolonged anesthetic administration lead to redistribution of body heat from the core to the periphery.

Answer 129

This places the patient at an increased risk for hypothermia and complications

Question 130

vasoconstriction with resulting hypertension, compromised immune function, bleeding, untoward cardiac events, SSIs (surgical site infection), altered drug metabolism, increased pain, and shivering.

Answer 130

Complications associated with hypothermia can include

Question 131

resting energy expenditure and O2 consumption up to 500%, which can lead to hypoxemia and myocardial ischemia (angina).

Answer 131

Shivering can increase

Question 132

carbon dioxide production; increase heart rate, BP, and intracranial pressure; and significantly affect the patient’s comfort level.

Answer 132

Shivering can also increase

Question 133

is often accompanied by a fever that spikes in the afternoon or evening and returns to near-normal levels in the morning.

Answer 133

SSI (surgical site infection), particularly from aerobic organisms,

Question 134

respiratory tract may be infected from stasis of secretions in areas of atelectasis

Answer 134

respiratory tract may be infected

Question 135

may occur from catheterization.

Answer 135

Urinary tract infections (UTIs)

Question 136

may occur at the IV site.

Answer 136

Superficial thrombophlebitis

Question 137

VTE in the leg veins may raise temperature.

Answer 137

VTE in the leg veins

Question 138

are at risk for Clostridium difficile infections. Manifestations of C. difficile may include fever, diarrhea, and abdominal pain.

Answer 138

Surgical patients who receive antibiotic therapy c diff

Question 139

Intermittent high fever accompanied by shaking chills and diaphoresis suggests

Answer 139

septicemia (occur from wound or UTI esp in GI during surgery)

Question 140

is a muscle metabolism disorder that is triggered by general anesthetic agents.

Answer 140

Malignant hyperthermia (MH)

Question 141

Although often a late sign, it is characterized by a rapid rise in core body temperature and severe muscle rigidity

Answer 141

Malignant hyperthermia (MH) late symp

Question 142

tachycardia, hypercarbia, metabolic and respiratory acidosis, myoglobinuria, and elevated creatine kinase levels. MH is a life-threatening complication. While most cases of MH occur during general anesthesia, the 1-hour period right after surgery (e.g., in the PACU) is a critical time.1

Answer 142

Other signs of MH include

Question 143

causes: Effects of anesthesia, body heat loss during surgical procedure

Answer 143

Up to 12hr after surgery Hypothermia: ≤96.8°F (36°C)

Question 144

causes: Inflammatory response to surgical stress

Answer 144

First 48hr (postoperative days 1 and 2)
Mild elevation: ≤100.4°F (38°C)

Question 145

causes: Lung congestion, dehydration

Answer 145

First 48hr (postoperative days 1 and 2)
-Moderate elevation: >100.4°F (38°C)

Question 146

causes: Infection (e.g., wound, urinary, respiratory)

Answer 146

After first 48hr (postoperative day 3 and later)
-Elevation >100°F (37.8°C)

Question 147

include the use of warmed cotton blankets, socks, and reflective blankets and limiting skin exposure.

Answer 147

Passive warming measures

Question 148

involve the application of external warming devices, including forced air warmers; heated water mattresses; radiant warmers; heated, humidified O2; and warmed IV fluids.

Answer 148

Active warming measures

Question 149

opioids (e.g., meperidine).

Answer 149

Shivering can be treated with

Question 150

administration of dantrolene (Dantrium), measures to cool the patient (e.g., ice packs), and correcting acid-base imbalances.

Answer 150

Treatment for MH includes the

Question 151

with wound and IV site care.

Answer 151

Use meticulous asepsis

Question 152

,chest x-rays may be taken, and antipyretic drugs given. Depending on the suspected cause of the fever, obtain cultures of the wound, sputum, urine, or blood

Answer 152

fever develops treatment/ diagnosis

Question 153

antibiotics as soon as you obtain cultures.

Answer 153

a bacterial infection is the source of the fever, start

Question 154

, you may use body-cooling measures.

Answer 154

If the fever rises above 103°F (39.4°C)

Question 155

are the most common complications affecting as many as 80% of high-risk patients.

Answer 155

Postoperative nausea and vomiting (PONV) (GI problem)

Question 156

younger age (under 50 years of age), gender (female), history of motion sickness or previous PONV, nonsmoking status, action of anesthetics or opioids, and duration and type of surgery.
- Delayed gastric emptying and slowed peristalsis that result from handling of the bowel during abdominal surgery contribute to PONV, as does starting oral intake too soon after surgery.

Answer 156

Risk factors of Postoperative nausea and vomiting (PONV) (GI problem) include

Question 157

after surgery. It can be due to anesthetics used during surgery that may paralyze the intestine; immobility; changes in diet and fluid intake; and the use of opioids for pain relief. Opioids contribute to constipation by decreasing peristalsis and slowing fecal transport through the intestinal tract. They may also decrease a patient’s urge to defecate.

Answer 157

Constipation may occur

Question 158

is the temporary impairment of gastric and bowel motility after surgery

Answer 158

Postoperative ileus (POI)

Question 159

results from the handling or reconstruction of the intestine during surgery and limited dietary intake before and after surgery.

Answer 159

Postoperative ileus (POI) results

Question 160

may be reduced for 2 to 7 days.

Answer 160

After abdominal surgery, motility in the large intestine

Question 161

within several hours after surgery.

Answer 161

After abdominal surgery Motility in the small intestine resumes

Question 162

the use of opioids, immobility, older age, prior abdominal surgery, and early postoperative feeding.

Answer 162

Risk factors for POI include

Question 163

Use of opioid analgesia may

Answer 163

prolong the duration of POI.

Question 164

Abdominal cramps, increasing abdominal distention, constipation, nausea, vomiting, and dehydration

Answer 164

often accompany POI

Question 165

are intermittent spasms of the diaphragm caused by irritation of the phrenic nerve, which innervates the diaphragm.

Answer 165

Hiccups (singultus)

Question 166

by gastric distention, intestinal obstruction, intraabdominal bleeding, or a subphrenic abscess.

Answer 166

phrenic nerve may be irritated after surgery (cause hiccups)

Question 167

with acid-base and electrolyte imbalances

Answer 167

Indirect irritation of the phrenic nerve may occur (cause hiccups)

Question 168

Reflex irritation may come from drinking hot or cold liquids or from the presence of a nasogastric (NG) tube. Hiccups usually last a short time and stop spontaneously.

Answer 168

Reflex irritation cause hiccups

Question 169

passing gas or stool and the ability to tolerate oral intake without nausea or vomiting.

Answer 169

return of normal bowel motility is usually accompanied by

Question 170

clear liquids first and continue the IV fluids, usually at a reduced rate.

Answer 170

starting oral intake, offer

Question 171

Positioning the patient on the right side permits gas to rise along the transverse colon and aids its release.

Answer 171

positioning to allow gas

Question 172

may be given to stimulate colonic peristalsis and expulsion of gas and stool.

Answer 172

Bisacodyl (Dulcolax) suppositories

Question 173

is the relief of associated symptoms and return of normal GI function

Answer 173

goal of treatment for POI

Question 174

includes bowel rest or the withholding of solid foods with a gradual reintroduction of food starting with clear liquids. Advance the diet to solid food with an ongoing assessment of tolerance to oral intake.

Answer 174

Management POI

Question 175

may be needed to decompress the stomach to prevent nausea, vomiting, and abdominal distention.

Answer 175

NG tube

Question 176

and stimulation of salivary glands when the patient is NPO or has an NG tube.

Answer 176

Oral care is critical for comfort

Question 177

may be expected regardless of fluid intake

Answer 177

Low urine output (800 to 1500 mL) in the first 24 hours after surgery

Question 178

Causes include increased aldosterone and ADH secretion resulting from the stress of surgery; fluid restriction before surgery; and fluid loss through surgery, drainage, and diaphoresis

Answer 178

causes Low urine output (800 to 1500 mL) in the first 24 hours after surgery

Question 179

is more likely to occur after lower abdominal or pelvic surgery because spasms or guarding of the abdominal and pelvic muscles interferes with their normal function in micturition.

Answer 179

Urinary retention

Question 180

can be a sign of renal failure and is a less common, although more serious, problem after surgery. It may result from renal ischemia caused by inadequate renal perfusion.

Answer 180

Oliguria (diminished output of urine)

Question 181

If no voiding occurs, scan or percuss the suprapubic area for signs of bladder fullness or distention.

Answer 181

Most patients void within 6 to 8 hours after surgery.

Question 182

providing privacy, running water, offering water for the patient to drink, or pouring warm water over the perineum. Walking, preferably to the bathroom, and the use of a bedside commode are other measures to help withvoiding.

Answer 182

enhance voiding by

Question 183

(1) exogenous flora present in the environment and on the skin, (2) oral flora, and (3) intestinal flora

Answer 183

SSIs may result from wound contamination from 3 major sources:

Question 184

malnourished, immunosuppressed, or older, or who have had a long hospital stay or a lengthy surgical procedure (more than 3 hours).

Answer 184

incidence of SSI is higher in patients who are

Question 185

and may extend downward through deeper tissues. An abscess may form locally, or it may spread throughout entire body cavities, as in peritonitis.

Answer 185

SSI may involve the entire incision

Question 186

Local manifestations include redness, swelling, and increasing pain and tenderness at the site. Systemic manifestations are fever and leukocytosis.

Answer 186

Evidence of SSI usually does not become clear before the third to fifth postoperative day. sign n symptoms include

Question 187

, impair circulation and wound healing, and predispose the patient to infection

Answer 187

accumulation of fluid in a wound may create pressure

Question 188

in the first 24 hours.

Answer 188

abdominal incision with an accompanying drain will likely have a moderate amount of serosanguineous drainage

Question 189

only minimal serous drainage.

Answer 189

inguinal herniorrhaphy should have

Question 190

may occur with an SSI.

Answer 190

Purulent drainage

Question 191

from sanguineous (red) to serosanguineous (pink) to serous (clear yellow)

Answer 191

expect the drainage to change (types drainage)

Question 192

may be preceded by a sudden discharge of brown, pink, or clear drainage

Answer 192

Wound dehiscence (separation and disruption of previously joined wound edges)

Question 193

to avoid disturbing the graft site and promote graft acceptance. Specially trained nurses may change these dressings.

Answer 193

Skin graft dressings may stay in place for 3 to 5 days

Question 194

moderate to heavy drainage is occurring, or healing occurs other than by primary intention.

Answer 194

Use a multilayer dressing when drains are in place,

Question 195

, has little or no drainage, or has no drains in place, a single-layer dressing or no dressing is sufficient

Answer 195

If the wound is healing by primary intention

Question 196

patient acuity, access to follow-up care, and the potential for complications.

Answer 196

choice of discharge site is based on

Question 197

are often used to determine the patient’s general condition and readiness for discharge from thePACU.

Answer 197

Standardized scoring systems (e.g., Modified Aldrete Scoring System)

Question 198

give a hand-off report about the patient to the receiving nurse
-report summarizes the operative and postanesthesia period.

Answer 198

Before discharging the patient from the PACU to the clinical unit,

Question 199

• Patient awake, easily arousable (or baseline)
• Vital signs at baseline or stable
• No excess bleeding or drainage
• No respiratory depression
• O2 saturation >90%
• Pain controlled or acceptable
• Nausea and vomiting controlled
• Report given

Answer 199

PACU Discharge Criteria (Phase I)

Question 200

• All PACU discharge criteria (Phase I) met
• No IV opioid drugs for last 30 minutes
• Voided if appropriate to surgical procedure or orders
• Able to ambulate if not contraindicated
• Responsible adult present to accompany and drive patient home
• Written discharge instructions given and patient and caregiver understanding confirmed

Answer 200

Ambulatory Surgery Discharge Criteria (Phase II or Extended Observation)

Question 201

(1) a pharmacy for prescriptions, (2) a phone in the case of an emergency, and (3) follow-up care.

Answer 201

(discharge) Determine availability of caregivers (e.g., family, friends) and access to

Question 202

has decreased respiratory function, including decreased ability to cough and decreased thoracic compliance. These changes lead to an increase in the work of breathing and a decreased ability to eliminate drugs.

Answer 202

older adult careful caution

Question 203

is a common complication in older adults.

Answer 203

Pneumonia

Question 204

vascular function in the older adult is due to atherosclerosis and decreased elasticity in the blood vessels. Cardiac function is often compromised with limited compensatory responses to changes in BP and volume.

Answer 204

changes in elders

Question 205

Factors such as age, history of alcohol abuse, poor baseline cognition, hypoxia, metabolic imbalances, hypotension, and polypharmacy can contribute to postoperative delirium. Anesthetics, especially anticholinergic and benzodiazepine drugs, increase the risk for delirium.

Answer 205

risk for delirium in elder

Question 206

delirium, prolonged PACU stay, delayed discharge, readmission, delayed resumption of usual activities, and decreased patient satisfaction.

Answer 206

PONV and pain are common problems after ambulatory surgery. These can lead to