Exam 2: Infection, Pre,Post-Op Flashcards
1
Q
The body’s ability to resist disease is known as what?
A
Immunity
2
Q
What are some reasons for wide spread distribution of emerging infections?
A
Global travel
Population density
Encroachment into new environments
Misuse of antibiotics
3
Q
This occurs when a pathogenic organisms change in ways that decrease the ability of a drug to treat the disease
A
Resistance
4
Q
How have HCPs contributed to the development of drug resistance microorganisms?
A
- Giving antibiotics for viral infections
- Succumbing to patient pressure to prescribe unnecessary antibiotic therapy
- Using inadequate drug regimens to treat infections
- Using broad spectrum or combination agents for infections that should be treated w/ first-line medications (over-treating)
5
Q
How can patients contribute to the development of drug resistance microorganisms?
A
- Skipping doses
- Not taking antibiotics for the full duration
- Saving unused antibiotics “in case I need them later”
6
Q
A viral infection is NOT treated with what?
A
Antibiotics
7
Q
What are some patient and caregiver teaching to prevent antiobiotic resistance?
A
- Only take antibiotics prescribed to you
- Wash hands frequently (prevention)
- Follow directions when taking antibiotics
- Don’t request an antibiotic for flu or cold (not effective against viral)
- Finish your antibiotic (bacteria will survive, multiply, and then be harder to kill)
- Do not take left over antibiotics (may not be effective for new illness, may not be as effective if older, may not be enough doses left)
8
Q
Infections in older adults may have atypical manifestations such as what?
A
Cognitive and behavioral changes BEFORE emergence of fever, pain, changes in lab values.
9
Q
This type of precaution is used for infections spread by small particles in the air (chicken pox, measles, TB)
A
Airborne:
- N95
- Gown
- Gloves
- Eye protection
10
Q
This type of precaution is used for infections spread in large _____ by coughing, talking, or sneezing. (Influenza and bacterial meningitis)
A
Droplet:
- Mask
- Gown
- Gloves
- Eye protection
11
Q
This type of precaution is used for infections spread _____ (skin-to-skin or infected surfaces). C-diff, MRSA
A
Contact
- Gown
- Gloves
12
Q
What are three functions of the immune system?
A
- Defense
- Homeostasis
- Surveillance
13
Q
In the defense function of the immune system, what occurs?
A
- The body protects against invasions / prevents development of infection by attacking foreign antigens and pathogens
14
Q
During the homeostasis function of the immune system, the body does what?
A
Digests and removes damaged cellular substances
- Goal is to have the body’s different type of cell types stay uniform and unchanged
15
Q
During the surveillance function of the immune system, what are recognized and destroyed?
A
Mutations - recognized as foreigns cells and destroyed as result
16
Q
____ are substances that elicit an immune response.
These are made of protein, found on each cell, are unique to the person so the body can recognize itself.
A
Antigens
17
Q
Wha are the two ways immunity can be classified?
A
Innate and acquired
18
Q
What type of immunity am i:
- Present at birth
- First line defense against pathogens
- Involves a nonspecific response: (WBC response includes neutrophils and monoctyes)
- NOT antigen specific so response can occur within minutes
- No previous exposure is needed for response to occur
A
Innate immunity
19
Q
What type of immunity am i?:
- Development of antibodies as the result of an invasion of a foreign substance: BODY MAKES ANTIBODIES ITSELF!
- Each re-invasion results in a faster and stronger response
- May result naturally or artificially
- Immunity takes time because body is making antibodies, but is long lasting
- Memory cells present for antigen
A
Active acquired
20
Q
What are some examples of active acquired immunity?
A
Vaccine
Bee sting
21
Q
What type of immunity am i?:
- Host RECEIVES antibodies rather than making them
- Occurs injection w/ gamma globulin (serum antibodies)
- Has immediate effect but short lasting because people doesn’t make antigen and memory cells themselves
A
Passive acquired immunity
22
Q
What is an example of passive acquired immunity?
A
Transfer of immunoglobulins across placental membrane
23
Q
What is the process of the immune response to a virus?
A
- Virus invades body thru break in the skin and into cell
- Macrophage recognizes antigens on the surface of virus, digests it and displays virus (antigens) on its surface
- T helper cells recognizes the antigen displayed and binds to the macrophages, stimulating production of cytokines -> communication begins
- Cytokines instruct T helper cells and T cytotoxic cells to multiply. T heller cells release additional cytokines that cause B cells to multiply and make antibodies
- T cytotoxic cells and natural killer cells destroy infected body cells
- Antibodies bind to virus and mark it for destruction by macrophages
- Memory B and T cells stay behind to respond quickly if same virus attacks again
24
Q
Role of mononuclear phagocytes in the immune response
A
- Include monocytes in blood and macrophages in the body
- Capture, process, and present antigen to lymphocyte (T or B), which stimulates the immune response
25
B lymphocyte is found in what immunity:
A. Cell-mediated
B. Hummoral
B. Hummoral
26
T lymphocytes are found in what immunity:
A. Cell-mediated
B. Hummoral
A. Cell-mediated
27
______ act as messengers among the cell types and instruct cells to alter their proliferation, differentiation, secretion, or activity.
Cytokines
28
What is the major difference between cell-mediated and humoral immunity?
In humoral immunity, antibodies and B-cells drive the response while T-cells drive the response in cell-mediated
29
What are the types of hypersensitivity reactions?
Type I: IgE-Mediated
Type II: Cytotoxic
Type III: Immune-Complex
Type IV: Delayed Hypersensitivity
30
What type of hypersensitivity reaction am i:
Type I: IgE-Mediated
31
Urticaria and Anaphylaxis are examples of what type of hypersensitivity reaction
Type I: IgE-Mediated
32
What type of hypersensitivity reaction am i:
ANTIGEN: Cell surface of RBCs
RATE OF DEVELOPMENT: minutes to hours
MEDIATORS: complement lysis, macrophages in tissues
EXAMPLES: Tranfusion issues, goodpasture syndrome, graves' disease
Type II: Cytotoxic
33
Graves disease and blood transfusion reactions are examples of what hypersensitivity reaction?
Type II: Cytotoxic
34
What hypersensitivity reaction am i:
ANTIGEN: extracellular fungal, viral, bacterial
RATE OF DEVELOPMENT: hours to days
MEDIATORS: neutrophils, monocytes, macrophages, complement lysis
EXAMPLES: SLE, RA, Acute glomerulonephritis
Type III: Immune-Complex
35
What hypersensitivity am i:
ANTIGEN: Intracellular, extracellular
RATE OF DEVELOPMENT: over SEVERAL DAYS
MEDIATORS: cytokines and T cytotoxic cells
EXAMPLES: Contact derm
Type IV: Delayed Hypersensitivity
36
Contact dermatitis is an example of what kind of hypersensitivity reaction?
Type IV: Delayed Hypersensitivity
37
Wheal and flare is associated with what type of hypersensitivity reaction?
Type I: IgE-Mediated
38
TB test reaction is related to what hypersensitivity reaction?
Type IV: Delayed Hypersensitivity
39
What are the interventions for Anaphylaxis
- Epinephrine is the drug of choice (does have short half-life, sometimes needs to be followed by second injection & albuterol)
- Oxygen is another intervention
40
Nursing assessment for allergic response: subjective data
Past health hx:
* Reccurent respiratory problems
* Seasons exacerbations
* Unusual reactions to insect bites / stings
* Past / present allergies
* Food intolerances -> What food, what reaction
* Family hx of allergic reactions
Medications:
* Unusual reactions to any medications: **WHAT IS THE ALLERGY**
* Use of OTC or Rx medications for allergies -> how often
Social & Environmental
* Pets, trees, plants on property
* Polluntants in air: what environment are they around most
* Cooling and heating systems in the house -> how often are they checked
* Home environment: dust?
41
Nursing assessment for allergic response: objective data
Integumentary
* rashes, urticaria, papules, dryness, scaliness, scratching, irritation
EENT
* Eyes: conjunctivities, rubbing/excessive blinking, dark circles under eyes -> "allergic shiner"
* Ears: diminshed hearing, reccurent ear infections, scarred tympanic membranes
* Nose: polyps, itchy/running nose, sneezing, repeated sneezing, recurrent nose bleeds swollen nasal passages
* Throat: continued throat clearing, swollen lips/tongue, palpable lymph nodes
Respiratory
* Wheeezing, stridor, thick sputum
42
What are some diagnostic studies that can be used with allergies?
* WBC: used to diagnose immunodeficiency
* Test Sputum, nasal and bronchial secretions for presence of eosinophils (will be increased in allergic reactions)
* Skin testing for specific allergens
43
What are some teaching / interventions that can be done w/ allergen recognition and control?
*** Need to identify offending allergn **
* Unlikely that pt will be totally desensitized or completely symptom free
* Environmental control: changing occupation, moving to different climate, sleeping in air conditioned room, dusting daily, covering mattresses/pillows w/ hypoallergic covers, wearing mask outdoors
* Medications available, may need to be used -> provide education on use, s/e, etc.
*
44
What are the major categories of drugs used for symptomatic relief of allergies?
* **Antihistamines**
* **Corticosteroids**
* **Antipuritic**
45
Allergy relief: antihistamines
* Best for allergic rhinitis & uriticaria, edema, pruritus --> not for severe reactions
* Complete w/ histamine receptor sites, block histamine effect
* Best if taken as soon as allergy symptoms appear
## Footnote
Cimeditine, Diphenhydramine, Famotidine
46
Allergy relief: Corticosteroids
* Effective in relieving allergic rhinitis
* Nasal or oral options
47
Allergy relief: Antipyretic
* Used for discomfort but do not reduce the allergy response
* Applied topically
## Footnote
Calamine lotion, Menthol
48
Allergy relief: Epinephrine
* Very short term, needs to be followed up by other meds such as corticosteroids or antihistamines -> HAS SHORT HALF-LIFE, MORE THAN ONE INJECTION MAY BE NEEDED
* Administered either IM, 90 degrees into top of thigh slightly to the outside. Hold in place 2-3 seconds
* Allergy bracelets should be worn notify others about allergy and med to use
49
What are some sample questions to ask a patient during an allergy assessment?
* Tell me more about your allergies
* What were your previous allergic reactions like
* What do you currently use to help control your allergies
| ALWAYS OPEN-ENDED AND THERAPEUTIC
50
What is the difference between a side effect and an allergy?
* An allergy is an **adverse drug reaction** mediated by an immune response (e.g., rash, hives).
* A side effect is an **expected and known effect of a drug** that is not the intended therapeutic outcome.
51
Hives, anaphylactic shock, cardiopulmonary compromise are an example of:
A. Side effect
B. Allergic reaction
B. Allergic reaction
52
Nausea, constipation, diarrhea, idiosyncratic reactions are examples of
A. Side effects
B. Allergic reactions
A. Side effects
53
A patient comes into the clinic with a bacterial infection, what is the expected treatment?
Antibiotics
54
What is the expected treatment for viral infections?
* Symptomatic treatment
* If appropriate: antiviral meds, vaccines
55
A patient diagnosed with a fungal infection can expect to recieve a medication from what drug class?
Antifungal
## Footnote
"Azole"
56
Labs for infection: WBC
Systemic response to infection
* Normal: 5,000-10,000
* 14,000+ is cause for alarm (unless patient is autoimmune)
* Less than 5,000 indicates immunosupression
57
Labs for infection: CRP
| C-Reactive Protein
* Detects inflammation but doesn't explain cause/location
* Less than 1mg/L is "normal"
* Will be elevated if inflammation is present
58
What are some ways a nurse can break the chain of infection?
* Frequent hand washing
* Vaccination
* Practicting standard precautions with ALL patients
* Practicing transmission-based precautions with appropriate patients
59
Lab Values: RBC
4.5 - 6.0
* Decreased: anemia: can be internal bleeding. **Can affect the body's ability to transport oxygen and nutrients around the cardiovascular system **
* Increased: can indicate kidney disease, increase risk for blood clots
60
Lab Values: Hbg
12 - 17.5
High: too many RBCs, risk of clotting
Low: anemia, lack of o2 in tissues, increased risk of complications
61
Lab Values: Hct
37-52%
* High: can indicate dehydration, heart/lung disease
* Low: anemia, lack of oxygen and nutrients to needed areas
62
Lab Values: Plt
150,000 - 450,000
High: Clotting
Low: bleeding, not enough clotting factor to stop bleeding
63
Lab values: BUN
10-20
High: kidney injury or damage, dehydration
Low (RARE): malnutrition, liver disease
64
Lab Values: Serum Creatinine
0.6 - 1.2
High: kidneys not filtering/working well, dehydration
Low: kidney disease, malnutrition
65
Lab Values: Fasting Blood Glucose
Book: 65 - 100 (Shar: 90-100)
High: High levels of blood glucose in the body, decreased wound healing because it attracts bacteria
66
Lab Values: A1C
5-7%
* Shows average of BG over last 3 months
High: increased risk of developing DM
67
Lab Values: CRP
* Less than 1mg/dL is NORMAL / no inflammation
* Sign of inflammation in the body, doesn’t say where it takes place
68
Lab Values: Sodium
135-145
69
Lab Values: Potassium
3.5-5
## Footnote
Know that even small differences in Potassium levels like 3.3 or 3.2 is significant.
70
Lab Values: Calcium
8.5 - 10.5
* Calcium ↑ = Excess calcium in the blood due to excess bone breakdown, thyroid disease, or excess calcium intake
71
Lab Values: Serum Albumin
3.5 - 5
High: signifies dehydration
Low: Water leaving blood vessels and goes to tissues -> EDEMA
## Footnote
**ALBUMIN IS A PROTEIN THAT HELPS KEEP FLUID IN BLOOD FROM LEAKING INTO OTHER TISSUES**
72
Lab Value: AST, ALT
10-35
High: liver disease, damage
73
Lab Values: PT
11-14 seconds
* High: **BLEEDING RISK** It takes longer for the blood to clot, lack of blood clotting proteins, serious liver damage or cirrhosis
74
Lab Values: APTT
30 - 40 seconds
High: longer for blood to clot: BLEEDING
75
Lab Values: PTT
60 - 70 seconds
High: takes longer for blood to clot (liver disease, kidney disease, blood thinner tx)
76
Lab Values: INR
1 (Therapeutic 2-3)
High: Blood clots slower than desired
Low: Blood clots quicker than desired
77
Lab Values: Specific Gravity
1.010-1.030 (ten-ten and ten-thirty)
* SG ↑ = Concentrated Urine (insufficient fluid intake, fluid retention, lack of urinary output)
* SG ↓ = Clear urine
78
What are the goals of the **nursing assessment **of the preoperative patient?
* Establish baseline for comparison in intraoperative and postoperative periods
* Determine pt's psychologic status and reinforce coping strategies
* Determine physiologic factors related to surgical procedure that can contribute to operative risk factors
* Participate in identification and documentation of surgery site
* Identify Rx, OTC, herbs that may result in drug reactions
* Review results of preoperative diagnostic studies, share info w/ HCP
* Identify cultural and ethinic factors that may affect surgical experience
* Determine if pt recieved adequate info from surgeon to make informed decision to have surgery (sign consent form)
79
What are the primary goals of the **patient interview** in the preoperative period?
* Obtain patient's health history, including medication and food allergies
* Provide and clarify information about planned surgery
* Assess emotional state, and rediness for surgery
80
What medications should patients inform HCP that they are taking?
Insulin
Anticoagulant
Heart medications
Certain herbals - gingko, garlic, ginseng, Vitamin E
81
What are some examples of questions you should ask your patient about the surgery
* What concerns do you have regarding your surgery?
* What medications (OTC, Rx, Supplements) are you currently taking?
* What are your allergies - food, drug? What are the reactions?
* What are your expectations regarding your surgery?
82
Preoperative teaching: sensory
What patients will hear, see, feel, smell, etc.
* Preoperative holding area may be noisy
* OR may be loud (beeping) and cold
* OR lights will be bright
* Drugs and cleaning solutions may be odorus
83
Preoperative teaching: procedural
Specific details
* Where patient will go (holding area, OR, PACU, etc)
* Physical prepratory measures (bathing, bowel prep, etc)
* What to bring, wear, etc.
* Food, fluid restrictions
* Purpose of frequent VS
* Why turning, deep breathing, coughing important after surgery
84
Properative teaching: Process
General flow
* IV will be inserted in holding area
* Surgeon will sign preoperative area
85
What are some priority teaching topics during the preoperative period?
* Fluid/Food restrictions
* Prepratory expectations: shower, bowel prep, etc.
* Deep breathing, coughing -> teach back, do w/ patient
* What medications to take / not take
* Expectations of surgery -> what to expect / what they make leave surgery with (tubes, drains, etc. and why)
86
Why is food and fluids restricted w/ surgery?
Reduces risk for aspiration and N&V
87
Herbals & Supplements: Astragalus & Gingseng
Increase BP before surgery
88
Herbals & Supplements: garlic, vitamin E, gingko, fish oil
Increase bleeding
89
Herbals & Supplements: Kava and valerian
Can cause excessive sedation
90
In general, when should you tell patients to stop taking herbs?
2 - 3 weeks before surgery
91
In general, when should you tell patients to stop taking multi vitamins?
Day before surgery
* Taking on empty stomach can cause N&V after surgery
92
What patient information should you report to the anesthesiologist?
* If the patient is taking meds/supplements/herbs that interfere with the anesthetics
* Allergies
93
What patient information should you report to the surgeon?
* Extreme fears regarding procedure
* Pt's drug hx, allergies
* Use of herbs that can interfere w/ procedure
* If religion is against blood tranfusion
* Abnormal diagnostic studies (i.e, infection -> cancel procedure?)
* Changes needed OR: If pt thin/obese: arrangements needed (padding, larger/longer instruments, etc)
94
What is the nurse's responsibility regarding informed consent?
* Witnessing the signed consent
* Patient advocate: making sure pt understands procedure, educating pt that consent can be withdrawn, contact surgeon if clarification is needed
95
Pre-op medications: Antibiotics
Prevent pre-op infection
## Footnote
Cefazolin
96
Pre-op medications: Anticholinergics
- Decreases oral & respiratory secrections
- Prevents N&V
## Footnote
Atropine
97
Pre-op medications: Antiemetics
Promote gastric emptying while preventing N&V
## Footnote
Odansetron (Zofran), Metoclopramide
98
What data should you hand-off to a surgical nurse?
## Footnote
Surgical RN hand-off BEGINS at the door to the OR
**Make sure you have the RIGHT patient undergoing the RIGHT procedure, at the RIGHT location, and at the RIGHT time.**
* Patient information (name, DOB)
* Baseline pre-op vitals & labs
* Pt medications (Rx, OTC, Supplements)
* Pt allergies
* Plan of care / interventions
* Surgery info -> location correct?
* Record of valuables, jewerly, clothes
* H&P listed on chart
* Signed informed consent
* Previous procedures
99
The goal of the PACU is what?
Maintain patient safety during recovery from anesthesia and and identify actual and potential pt problems
100
What are the priority assessments done at the PACU?
***INITIALLY START W/ ABCs***
* R/R and depth, lung sounds, heart sounds, o2 levels (pulse ox), ECG --> MONITOR EVERYTHING TO BASELINE
* BP, body temperature, cap refill, color, temp and moisture of skin, apical and peripheral pulses (always want to check BELOW surgical site for circulation)
* Neuro check -> LOC, Orientation, sensory and motor status, size & equality of pupils
* Surgical site: Dressings/incisions (if visible), drains: type, patency, drainage type. IV assessment: location/condition of sites, solutions infusing
* Pain: assess pain using scale, look for nonverbal indicators of pain for those having difficulty communicating
101
What are some signs of inadequate oxygenation?
Cardiovascular
* Hyper/hypotension
* Tachy/Bradycardia
* Delayed cap refill
* Weak peripheral pulses
* Decreased o2 sat
CNS
* Restlessness, Agitation, Confusion, muscle twitching, seizure, coma
Integumentary
* Flushed, cool, or moist skin
* Cyanosis
Renal system
* Decreased urine output (<0.5mL/kg/hr)
Respiratory
* Increased to absent respiratory effort
* Use of accessory muscles
* Abnormal breath sounds
* Abnormal aterial blood gas volume
102
Interventions performed in PACU: Airway/Breathing (Respiratory)
* Patient in LATERAL recovery position if unconscious
* Patient's head of bed elevated to 30 degrees once consciousness is regained
* O2 therapy via NC or face mask
* Teach deep-breathing exercises
* Use incentive spirometer up to 10x/hrs
* Change positions every 1-2 hrs
* Promote early ambulation if possible
103
Interventions performed in PACU: Cardiovascular
* Promote ambulation
* O2 therapy
* Continue to monitor BP
* Depending on where the surgery took place, assess pedal and/or radial pulses
* Assess the skin for temp, color, capillary refill
104
Interventions performed in PACU / Post-Op: Neuro
**ALWAYS CHECK FOR PATIENT SAFETY**
- Monitor LOC, orientation, sensory/motor status
- Size and equality of pupils
- Evaulate respiratory function if agitation occurs
105
Interventions performed in PACU: Pain / Discomfort
Perform pain assessment -> location, severity using appropriate pain scale
* Pharm methods -> PCA, analgesics (usually opioids)
* Non pharm -> distraction, guided imagery, thermal therapy
106
Interventions performed in PACU: Temperature Changes
* Hypothermia: blankets, socks, air warmers, O2 therapy to remedy shivering
* Antibiotics if a bacterial infection triggers infection (>100F)
107
Interventions performed in PACU: GI and GU
* NPO: IV fluids
* PO: Oral fluids
* Administer antiemetics
* Help into normal position when voiding
* Ambulate to and from bathroom
* Monitor i/o, quantity and characteristics of voiding
108
Respiratory problems trying to prevent in PACU and Post-Op (after PACU?)
* Airway obstruction - tongue falls back
* Aspiration - inhalation of gastric contents
* Atelectasis - alveolar collapse
* Hypoventilation - decreased r/r
* PE
* Pulmonary edema
* Bronchospasm
109
PACU complication: Airway obstruction
* Tongue falls back
* Intervention: head tilt, jaw thrust, patient stimulation, artificial airway
110
PACU / Post Op Complication: Aspiration
* Due to depression of respiratory protective airway reflexes because of anesthesia
* Intervention: PREVENTION IS KEY, O2 therapy, cardiopulmonary support, antibiotics
111
PACU / Post Op Complications: Atelectasis
* Alveolar collapse
* Can be caused by bronchial obstruction (by retained secretions, decreased respiratory excursion, or GA)
* Interventions: Deep breathing, incentive spirometer, o2 therapy, bronchodilator
112
PACU / Post Op Complication: Bronchospasm
* Can result in airway edema -> leading to secretion build up in air way
* Will have wheezing, dyspnea, accessory muscle use
* Interventions: o2 therapy, bronchodilator
113
PACU / Post-Op Complication: Pulmonary Edema
* Fluid accumulation in alveoli
* Intervention: o2 therapy, diuretic, fluid restriction
114
PACU / Post Op Complication: Pulmonary Embolism
* Usually comes from DVT
* Prevention is key (same prevention as DVT -> early ambulation, SCDs, etc.)
115
All surgical patients are at risk for Atelectasis. How can this be prevented?
* Deep breathing, coughing, incentive spirometer -> helps prevent alveolar collapse and move secretions to larger airways
116
PACU and Post-Op complication: Hypo/hypertension
Hypotension: usually from fluid/blood loss.
* Interventions: increase in fluids (IV), vasopressors if extremely low, O2 therapy
Hypertension: CNS stimulation: pain, anxiety, etc.
* Intervention: administer analgesic, anxiety medication. Antihypertensive.
117
PACU and Post-Op (after PACU) Cardiovascular complications -> Important assessments and Complication prevention include:
Assessments:
* Vitals
* EKG Reading (compare to baseline)
* Color of skin
* Cap refill
* Pedal/Radial pulses
* Heart sounds
* Edema
* DVT? -> redness, increased leg side
Interventions
* SCDs
* Ted Hose
* Ambulation
* ROM exerecise (passive, active)
* Meds (anticoagulant, Aspirin)
118
What assessments in PACU that could indicate cardiovascular problems
* Systolic BP <90 or >160
* Pulse rate <60bpm or >120bpm
* Pulse pressure (difference between systolic and diastolic BP) narrows
* BP trends gradually decrease or increase over several consecutive readings
* Change in heart rhythm
119
PACU complication: neuro & psych assessments
* Assess LOC, orientation, memory and ability to follow commands
* Most common cause of agitation is *hypoexmia* monitor respiratory function -> if ruled out, sedation may be appropriate.
* SAFETY MOST IMPORTANT: having side rails up, securing equipment, using patient identifiers before med admin
120
What patients are at high risk for respiratory complications?
* Had general anesthesia
* Older than 55
* Have hx of tobacco use
* Have pre-existing lung disease or sleep-disordered breathing
* Obsese
* Co-morbidities (DM, HTN)
* Undergone airway, thoracic, or abdominal surgery
121
Respiratory assessments to perform in the PACU / Post-Op
Assessments
* Decreased/absent breath sounds
* Look for abdominal or accessory muscle use when breathing
Interventions
* Repositioning q1-2h
* Proper positioning - supine position and head elevated
* Incentive spirometer use up to 10 breaths/hr
* Deep breathing and coughing
* Abdominal incision - splint it with an abdominal binder or a pillow while coughing (post-op abd surgery)
122
Pain nursing assessments in the PACU
* q15 min VS
* Self-report pain score
* Monitor non-verbal indicators of pain
* Full bladder may also cause pain: assess for this (may need bladder scan)
123
Nursing assessments done in the PACU for temperature changes
* Take temp on arrival to PACU and qhr if normal -> q15 if temp high/low
* Assess color, temperature of skin
* Observe for early signs of inflammation and infection that may precede fever so treatment can be implemented early
124
GI/GU nursing assessments & interventions in the PACU / Post-Op
* Ask about feelings of nausea
* Determine quality, quantity, color of vomitus if it occurs
* Assess abdomen for distention, BS (usually absent directly after surgery)
* **DON'T GIVE FOOD UNTIL PERISTALISIS RETURNS**
* Stool softners, fluids, exercise/mobility can help aid in GI motility
* antiemetics can help prevent N&V
* Try pouring warm water on the perineum (for women)
125
What patient information indicates an increased risk?
* Increased age
* Increased WBC -> indication of infection
* Electrolyte changes
* Significant blood loos during surgery
* SBP <90 or >160 (look for extremes)
* Pulse <60 BPM or >120 BPM (look for extremes)
126
Important information for patients to know for discharge: wound drainage
* Some drainage is normal
* Serous (clear, watery drainage is to be expected)
* Let HCP know if it is sanguineous (bright red/bloody) or foul odor
127
Important information for patients to know for discharge: voiding
* Normal 30mL / hr (0.5mL/kg/hr) -> if less is occur, notify HCP
* If flatus, BM is absent or slowed, also notify HCP
128
Important information for patients to know for discharge: wound healing
* Hand hygiene critical for proper healing
* Modifications to life may need to occur (sugery usually impacts movement)
* Should have someone be with them for first few days following procedure to assist around house
* Diet modifications: more Vitamin A, B, C, E protein, carbs, healthy fats, fluids
* Know when, where, with whom to follow up with
129
Following a surgical procedure, a low Hgt and/or Hgb indicates what?
Anemia -> lack of oxygen & nutrients being brought to tissues. IMPORTANT FOR HEALING
130
Following a surgical procedure, a high PTT indicates what?
Bleeding: lack of clotting factors
131
Following a surgical procedure, a low Albumin can indicate what?
Decreased protein in blood to hold fluids in blood -> goes into tissues instead. EDEMA, risk for delayed healing
132
Following a surgical procedure, low RBC means what?
Blood loss, decresed oxygen carrying capacity. Delayed wound healing
