Exam 4: Chapter 19: Postoperative Nursing Management Flashcards
What is the PACU?
Area where postoperative patietns are monitored as they recover from anesthesia; formely referred to as recovery room
What is Phase I PACU
Used during the immediate recovery phase, intensive nursing care is provided.
Wht is Phase II PACU
The patient is prepared for self-care or an extended care setting
What is Phase III PACU
The patietn is prepared for discharge.
Patients may remain in PACU for as long as
4-6 hours
The nursing management objective for the patietn in the PACU are to
provide care until the patient has recovered form the effects of anesthesia
Is Oriented
Has Stable Vital Signs
Shows no Evidence of Hemorrhage
Assessing the Patient: Frequent and skilled assessments of the
patients airway, respiratory function, cardiovascular function, skin color, level of consciousness, and ability to respond to command
After the initial assessment, vital signs are monitored and patients general physical status assessed and documented every
15 minutes
Responsibilites of the PACU Nurse: Review
pertinent information, baseline assessent upon admission to unit
Responsibilites of the PACU Nurse: Administration of
postoperative analgesia
Responsibilites of the PACU Nurse: Transfer report to
another unit or discharge patient to home
Primary objective in the immediate postoperative period is to
maintain ventilation and thus prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (Excess carbon dioxide in the blood)
Maintain a Patent Airway: Nurse assesses
respiratory rate and depth, ease of respiration, oxygen saturation, and breath sounds
What is Hypo-pharyngeal Obstruction?
When the patient lies on their back , the lower jaw and the tongue fall backward and the air passages become obstructed
Signs of Occlusion include
choking; noisy and irregular respiration’s ; decreased oxygen saturation ; blue dusk color
Maintaining a Patent Airway: Primary Consideration
Necessary to maintain ventilation, oxygenation
Maintaining a Patent Airway: Provide
supplemental oxygen as needed
Maintaining a Patent Airway: Assess breathing by
placing hand near face to feel movement of air
Maintaining a Patent Airway: Keep head of bed
elavated 15-30 degrees unless contraindicated
Maintaining a Patent Airway: May require
sunctioning
Maintaining a Patent Airway: If vomiting occurs,
turn patient to side
Maintaining Cardiovascular Stability: To monitor cardiovascular stability, the nurse assesses the patients level of
consciousnes
Vital Signs
Cardiac Rhythm
Skin Temperature, Color, and Moisture
Urine Output
Maintaining Cardiovascular Stability: Primary cardiovascular complications seen in PACU include
hypotension and shock
Hemorrhage
Hypertension
Dysrhythmias
Hypotension can result from
blood loss, hypoventilation, position changes, pooling of blood, or side effects of medications
If amount of blood loss exceeds ____, replacement is usually indicated
500 mL
A systolic blood pressure less than ____ is usually considered immediately reportable
90 mmHg
A previously stable blood pressure hat shows a downward trend of ___ at each 15-minunte reading should also be reported
5 mmHg
Maintaining Cardiovascular Stability: The clasic signs of hypovolemic shock are
Pallor
Cool, Moist Skin
Rapid Breathing
cyanosis of the Lips., Gums, and Tongue
Rapid, WEak, Thready Pulse
Narrowing Pulse Pressure
Low Blood Pressure
concentrated Urine
Maintaining Cardiovascular Stability: Hypovolemic Shock can be avoided largely by
timely administration of IV fluids, blood, blood products and medications that elevate blood pressure
Maintaining Cardiovascular Stability: Primary intervention for hypovolemic shock is
volume replacement, with an infusion of lacated Ringer solution, 0.9% NaCl solution, colloids, or blood compoennt therapy
Maintaining Cardiovascular Stability: What is usually monitored to provide information on the patients repiratory and cardiovascular status
Respiratory Rate, Pulse Rate, Blood Pressure, Blood Oxygen Concentration, Urinary Output, and Level of Consciousness
Pt with Hemorrhage presents with Hypotension;
Rapid, Thready Pulse;
Disorientation;
REstlessness
oliguria
Cold, Pale Skin
Early phase of shock will manifest in feels of
apprehension, decreased CO, and vascular resistance
In hemorrhage, the patient will feel
cold and may experience tinnitus
Lab values for hemorrhage may show
sharp drop in hemoglobin and hematocrit levels
Primary Hemorrhage characteristic
Hemorrhage occurs at the time of surgery
Intermediary Hemorrhagecharacteristic
Hemorrhage occurs during the first few hours after surgery when the rise of blood presure to its normal level dislodgres insecure clots from untied vessels
SEcondayr Hemorrhage characteristic
Hemorrhage may occur sometime after surgeyr if a suture slips because a blood vessel was not securely tied
Capillary Hemorrhage Characteristic
Hemorrhage is characterized by slow, general ooze
Venous Hemorrhage Characeristic
Darkly colored blood flows quickly
Arterial Hemorrhage Characteristic
Blood is bright red and appears in spurts with each heart bit
Evident Hemorrhage Characteristic
Hemorrhage is on the surface and can be seen
Concealed Hemorrhage Characteristic
Hemorrhage is in a body cavity and cnanot be seen
Hypertension is common in the
immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention
Dysrhythmias are associated with
electrolyte imbalance , altered respiratory function, pain, hypothermia, sstress, and anesthetic agents
Opioid analgesic medications are given mostly by
IV in the PACU
IV Opioids provide
immediate pain relief and are short acting, this minimzing the potential for drug interactions or prolonged respiratory depression
Relieving Pain and AxietY: Assess
patient comfort
Relieving Pain and AxietY: Control of
environment: quiet, low lights, noise level
Relieving Pain and AxietY: family visit,
dealling with family anxiety
Alternative techniques to contrtol Postoperative Nausea and Vomiting ?
Deep Breathing
Aromatherapy`
Patients remains in the PACU until
fully recovered form the anesthetic agent. Indicators include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level
Aldrete Scores is used to determine
patients general condiiton and readiness for transfer form the PACU
Aldrete score is usually between
7-10 before discharge
Discharge Preparation: Patient and caregiver are informed about
expected outcomes and immediate postoperative changes anticipated
Discharge Preparation: Provide
written, verbal instructions regarding follow-up care, complications, wound care, activity, medications, diet
Discharge Preparation: Give prescriptions and phone numbers ; discuss
actions to take if complications occur
Discharge Preparation: Patients are not to
drive home or be discharged to home alone. Sedation, anesthesia may cloud memory, jugement, affect ability
Continuing and TRansitional Care: TRansitional nurse assesses
the patients physical status (respiraotry and cardiovascular status, adequancy of pain management, the surigcal incision, surgical complications) and the patients and family ability to adhere to recommendations given at the time of discharge
Continuing and TRansitional Care: Nursing interventions may include
changing surgical dressings, monitoring the patency of a drianage system, or administering medications
During the first 24 hours after surgery, nursing care of the hospitalized patient on the medical-surgical unit involves
continuing to help the patient recover form the effects
frequently assessing the patients physiologic status
monitoring for complications
managing pain
implementing measures designed to achieve the long-range goals
In the initial hours after admission to the clinic unit, what are the primary concerns?
Adequate Ventilation
Hemodynamic Stability
Incisional Pain
Surgical Site Integrity
N/V
Neurologic Status
Nursing Management After Surgery: The Pulse Rate, Blood Pressure, and Respiration Rate are recorded at least every
15 minutes for the first hour, and every 30 minutes for the next 2 hours
Nursing Management After Surgery: Temperature is monitored every
4 hours for the first 24 hours
Assessment of the hospitalized postoperative patient includes
monitoring vital signs and completing a review of systems upon the patietns arrival to the clinical unit
Assessment: REspiratory status is important because
pulmonary complications are among the most frequent and serious problems encountered by teh surgical patient
Assessment: Why is Flash Pulmonary Edema a possible complication
This occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive presure
Assessment: Signs and Symptoms of Flash Pulmonary Edema
Agitation, Tachypnea, Tachycardia, Decreased Pulse Oximetry REadings
Frothy Pink Sputum
Crackles on Auscultation
Hospitalized Patient Recovering From Surgery Nursing Diagnosis
Risk for Ineffective Airway Clearance
Acute Pain
Decreased CO
Activity Intolerance
Inpaired Skin Integrity
Ineffective Thermoregulation
Hospitalized Patient Recovering From Surgery Potential Complications
Pulmonary Infection / Hypopxia
VTE, DVT, PE
Hematoma
Infection
Wound Dehiscence or Evisceration
Hospitalized Patient Recovering From Surgery: Major goals inlcude
optimal respiratory function, relief of pain, optimal cardiovascular function
Increased Activity olerance
Unimpaired Wound Healing
Maintenance of Body Temperature
Maintenance of Nutritional Balance
Preventing Respiratory Complications: What combines to put the patient at risk for respiratory complications, particular atelectasis (alveolar collapse; incomplete expansion of the lung)
REspiratory depressive effects of opioid medications
Decreased lung expansion secondary to pain
Decreased mobility
Preventing Respiratory Complications: Atelectasis reamins a risk for the patient who is
not moving well or ambulating or who is not performing dddeep breathing and coughing exercises or using an incentive spirometere
Preventing Respiratory Complications: Signs and Symptoms include
Decreased Breath Sounds
Crackles
Cough
Preventing Respiratory Complications: Pneumonia is characterized by
chills and fever
Tachycardia
Tachypnea
Preventing Respiratory Complications: How does Hypostatic Pulmonary Congestion occur?
Caused by a weakened cardiovascular system that permits stagnation of secretiosn at lung bases , occurs in oldedr patients who are not mobilized efficitely
Preventing Respiratory Complications: Symptoms of Hypostatic Pulmonary Congestion?
Symptoms Vague. Slight elevation of temperature, pulse and respiratory rate as well as cough
Preventing Respiratory Complications: Physical Examination for Hypostatic Pulmonary Congestion reveals
dullness and crackles at the base of the lungs. If it progresses , it may be fatal
Preventing Respiratory Complications: Types of Hypoxemia that can affect postoperative patietns are
subacute and episodic
Preventing Respiratory Complications: Subacute Hypoexmia is a
constant low level of oxygen saturation when breahting appers normal
Preventing Respiratory Complications: Episodic Hypoxemia develops
suddenly, and the patient may be at risk for cerebral dysfunction, myocardiac ischemia, and cardiac arrest
Preventing Respiratory Complications: Risk for Hypoxemia is increased in patietns who have undergone
major surgery, particularly abdominal, are obese, or have preexisting pulmonary problems
Preventing Respiratory Complications: Hypoxemia is detected by
pulse oximetry, which measures blood oxygen saturation
Preventing Respiratory Complications: Factors that affect the accuracy of pulse oximetry readings include
cold extremities, tremors, atrial fibrillation, arylic nails, and blue or black nail polish
Preventing Respiratory Complications: Crackles indicate
static pulmonary secretions that need to be mobilized by coughing and deep-breathing exercises
Preventing Respiratory Complications: To clear secretions and prevent pneumonia, nurse encourages the patient to
turn frequently, take deep breaths, cough, and use the incentive spirometer at least every 2 hours
Preventing Respiratory Complications: Pulmonary exercises should begin as ssoon as
the patient arrives on the clinical unit and continue until the patietn is discharged
Preventing Respiratory Complications: Taking several deep breaths helps
expel residual anesthetic agents, mobilize secretions, and prevent aelectasis
Preventing Respiratory Complications: Analgesic agents are given to permit
more effectice coughing and oxygen is given as prescribed to prevent or relieve hypoxia
Preventing Respiratory Complications: To encourage lung expansion, the patient is encouraged to
yawn or take sustained maximal inspirations to create a negative intrrathoracic pressure
Preventing Respiratory Complications: Coughing is contraindicated in patients who have
head injuried or have undergone intracarnial surgery, eye surgery, or plastic surgery
Preventing Respiratory Complications: Early ambulation increases
metabolism and pulmonary aeration and in general improves all body functions
Relieving Pain: Intesnse pain stimulates
the stress response, which adversely affects teh cardiac and immune systems
Relieving Pain: When pain impulses are transmitted, both
muscle tension and local vasoconstriction increase, further stimulating pain receptors
Relieving Pain: The nurse assesses the effectiveness of the medication periodically, beginning
30 minutes after administration or sooner if the medication is being delivered by patient-controlled analgesia (PCA)
Opiod Analgesic Medication: What appraoch is more effective at relieving pain?
The preventing appraoch, rather than PRN appraoch
What is teh Preventive Approach?
The medication is given at prescribed intervals rather than when the pain becomes severe or unbearable
What is PCA?
Patient-Controlled Analgesia
What are the two requirements for PCA?
They are understanding of the need to self-dose and the physical ability to self-dose
PCA Promotes
Patient Participation In Care
Eliminates Delayed Administration
Maintains Therapeutic Drug Level
Enables Patient to Move and Turn and Breath with Less Pain
Epidural infusions are used with caution in chest procedures because
the analgesic may ascent along the spinal cord and affect respiration
Intrapleural anesthesia involves the
administration of a local anesthetic by a catheter between teh parietal and visceral pleura. Provides sensory anesthesia without affected motor function .
Intrapleural Anesthesia allows more
effective coughing and deep breathing in condiitons such as cholecysectomy, renal surgery, adn rib fractures
What is used in the epidural infusion?
Locl Opioid or combination anesthetic
For pain that is difficult to control, a ___ may be used
Subcutaneous pain management system
What happens with a subcutaneous pain management system?
Nylon catheter is inserted at the site of the affected area. Catheter attached to a pump that delivers a continuous amount of local anesthetic
Other Pain Relief Measures: Nonpharmacologic measures include
Guided imagery, music, and implementation of healing touch have been successful clinical adjuncts used to decreased pain and anxiety
Promoting Cardiac Output: IV Fluid replacement may be prescribed for up to
24 hours after surgery or until the patient is stable and tolerating oral fluids
Promoting Cardiac Output: Close Montioring is indicated to detect and correect conditions such as
fluid volume deficit, altered tissue perfusion, and decreased cardiac output
Promoting Cardiac Output: Some patients are at risk for fluid volume excess secondary to
existing cardiovascular or renal disease , advanded age, or other factors
Promoting Cardiac Output: Nursing Management includes
assessing the patency of the IV lines and ensuring tha tthe correct fluids are given at teh prescribed place
Promoting Cardiac Output: If patient has an indwelling urinary catheter, hourly outputs are
monitored and should not be less than 0.5 mL/kg/hr
Promoting Cardiac Output: Oliguria is reported
immediately
Promoting Cardiac Output: What other things are monitored?
Elecrolyte Levels
Hemoglobin
Hematocrit Levels
Promoting Cardiac Output: Decreased hemoglobin and hematocrit levels can indicate
blood loss or dilution of circulaitng volume by IV fluids
Promoting Cardiac Output: If dilution is contributing ot the decreased levels , the hemoglobin and hematocrit will
rise as the tress response abates and fluids are mobilized nd excreted
Promoting Cardiac Output: Venous Stasis from dehydration, immobility, and pressure on leg veins during surgery put patient at risk for
VTE
Encouraing Activity: Early ambulation has a
significant effect on recovery and the prevention of complications (atectasis, hypostatic pneumonia, GI discomort, circulatory problems
Encouraing Activity: Ambulation reduces
postoperative abdominal distention by increasing GI tract and abdominal wall tone and stimulating peristalsis
Encouraing Activity: Early ambulation prevents
stasis of blood, and thromboembolic evens occur less frequently
Encouraing Activity: Examples of bed exercises that improve circulation?
Arm exercises (full range of motion, specifically abduction and external rotation of the shouldeR)
Hand and finger exerses
Foot exercises to prevent VTE, foot drop, and toe deformities
Leg Flexion and leg-lifting exercises to prepare the patient for ambultion
Abdominal and gluteal contraction exercises
Caring for Surgical Drains: What are surgical drains?
Tubes that exit the peri-incisional area, either into a portable wound suction devide (closed) or into the dressing (open)
Caring for Surgical Drains: Principle involved with drains is to
To allow the escape of fluids that could otherwise serve as a culture medium fo rbacteria
Caring for Surgical Drains: In portable wound usctioning
The use of gentle, constant suction enhances drainage of of these fluids and collapses the skin flaps against the underlying tissue, thus removing “dead” soace
Caring for Surgical Drains: Types of wound drains include
Penrose, HEmovac, and Jackson Pratt Drains
Changing the Dressing: Dressing is applied to a wound for the following reaons
Provie proper environment for wound healing
Absorb drainage
Splint or immobilize the wound
Protect the wound and new epithelial tissue
Protect from bacteria
Promote Hemostasis
Provide mental and physical comfort
Maintaining Normal Body Temperature: Patient is still at risk for
malignant hyperthermia and hypothermia
Maintaining Normal Body Temperature: Patients who have received anesthesia are susceptible to
chills and drafts
Maintaining Normal Body Temperature: Treatment includes
oxygen administration, adequate hydration, and proper nutrition including glycemic control
Maintaining Normal Body Temperature: PAtient is also monitored for
cardiac dysrhythmias
Maintaining Normal Body Temperature: The risk of hypothermia is greater in
older adults and in patietns who wre in the cool OR environment for prolonged periods
Managing GI Function and REsuming Nutrition: If risk of vomiting is high due to the nature of surgery, a
ng tube is inserted preoperatively and remains in place throughout the surgery adn the immediate postoperative period
Managing GI Function and REsuming Nutrition: If hiccupts persist, they may produce
considerable distress and serious effects such as vomiting, exhaustion and wound dehiscence
Managing GI Function and REsuming Nutrition: Postoperative distention of the abdomen results from
the accumulation of gas in the intestinal tract
Managing GI Function and REsuming Nutrition: Manipulation of the abdominal organs during surgery may produce a loss of normal peristalsis for
24-48 hours
Promoting Bowel Movement: REseatch suggests that ____ particuly following laprascopic surgery, can help restore bowel function and prevent paralytic ileus by promoting peristalsis
chewing gumq
Managing Voiding: What interferes with the perception of bladder fullness adn the urge to void?
Anesthetics, Anticholinergic agents, adn opioids
Promoting Bowel Movement: _____ may increase the likelihood of retention secondary to pain
Abdominal, pelvic, and hip surgery
Promoting Bowel Movement: Patient is expected to void within
8 hourus after surgery
Promoting Bowel Movement: If Patient has not voided in that time, what is performed to check for urinary retention?
Untrasound Bladder Scan or Bladder Ultrasonography
Promoting Bowel Movement: Postvoid residual urine may be assessed by using either
straight catheterization or an ultrasound bladderscanner
Promoting Bowel Movement: Intermittent catherterization may be prescribed every
4-6 hours until the patietn can void spontaneously and postvoid is less than 50 mL
Assessment after surgical procedure for the extremities incllude
having the patient move the hand or foot distal to the surgical site through full range of motion, assessing all surfaces for intact sensation, adn assessing peripheral pulses
Managing Potential Complications: What is a treatment for patients at high risk for VTE?
Prophylactic treatment .
Low-molecular-weight or low-dose heparin and low-dose warfarin are other anticoagulants that may be used
Managing Potential Complications: The stress response that is initiated by surgery inhibits the
thrombolytic system, resulting in blood hypercoagulability
Managing Potential Complications: What adds to the risk of thrombosis formation?
Dehydration, low CO, blood pooling in the extremities and bed rest
Managing Potential Complications: Factors that can increase risk of DVT?
Thrombosis
Mlignancy
TRauma
Obesity
Indwelling Venous CAtheters
And Estrogen Use
Managing Potential Complications: First symptom of DVT?
Pain or cramp in the calf although many patients are asymptomatic
Managing Potential Complications: DVT initial pain and tenderness may be followed by
painful swelling of the enitre leg, often accompained by fever, chills, and diaphoresis
Possible Respiratory Complciations?
Atelectasis
Pneumonia
Pulmonary Embolism
Aspiration
Possible CArdiovascular Complications
Shock
Thrombophlebitis
Possible Neurologic Complications
Delirium, Stroke
Possible Skin/Wound Complications
Breakdown, infection, dehiscence, evisceration, delayed healing, hemorrhage, hematoma
Possible GI Complications
Constipation
Paralytic Ileus
Bowel Obstruction
Possible Urinary COmplications
Acute Urine retention
Urinary Tract Infection
Possible Functional Complications
Weakness
Fatigue
Functional Decline
Possible Thromboembolic Complcations
Deep Vein Thrombosis
Pulmonary Embolism
What is a Hematoma?
A clot formation within the wound
How is a largge Hematoma treateed?
Sutures removed by the surgeon, clot evacuated, and wound is lightly packed with gauze
Managing Potential Complications: Wound infection may not be evident until at least
postoperative day 5
Managing Potential Complications: Signs and Symptoms of Wound Infection include
Increase Pulse Rate and Temperature
elevated WBC
Wound Swelling, Warmth, Tenderness, or Discharge
What does Serous fluid look like?
Thin, clear, watery plasma
what does sanguineous fluid look like?
bloody draineage, seen in deep partial-thickness
What does serosanguineous look like
Thin, watery, pale red to pink plasma with red blood cels
What does purulent fluid look like?
Thick, opaque drianage that is tan, yellow, green or brown
A meal should contain
high-protein that provide sufficient fiber, calories, and vitamins
