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NRSG 102: Med Surg 1 > Exam 4: Chapter 19: Postoperative Nursing Management > Flashcards

Exam 4: Chapter 19: Postoperative Nursing Management Flashcards

1
Q

What is the PACU?

A

Area where postoperative patietns are monitored as they recover from anesthesia; formely referred to as recovery room

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2
Q

What is Phase I PACU

A

Used during the immediate recovery phase, intensive nursing care is provided.

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3
Q

Wht is Phase II PACU

A

The patient is prepared for self-care or an extended care setting

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4
Q

What is Phase III PACU

A

The patietn is prepared for discharge.

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5
Q

Patients may remain in PACU for as long as

A

4-6 hours

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6
Q

The nursing management objective for the patietn in the PACU are to

A

provide care until the patient has recovered form the effects of anesthesia

Is Oriented

Has Stable Vital Signs

Shows no Evidence of Hemorrhage

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7
Q

Assessing the Patient: Frequent and skilled assessments of the

A

patients airway, respiratory function, cardiovascular function, skin color, level of consciousness, and ability to respond to command

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8
Q

After the initial assessment, vital signs are monitored and patients general physical status assessed and documented every

A

15 minutes

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9
Q

Responsibilites of the PACU Nurse: Review

A

pertinent information, baseline assessent upon admission to unit

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10
Q

Responsibilites of the PACU Nurse: Administration of

A

postoperative analgesia

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11
Q

Responsibilites of the PACU Nurse: Transfer report to

A

another unit or discharge patient to home

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12
Q

Primary objective in the immediate postoperative period is to

A

maintain ventilation and thus prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (Excess carbon dioxide in the blood)

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13
Q

Maintain a Patent Airway: Nurse assesses

A

respiratory rate and depth, ease of respiration, oxygen saturation, and breath sounds

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14
Q

What is Hypo-pharyngeal Obstruction?

A

When the patient lies on their back , the lower jaw and the tongue fall backward and the air passages become obstructed

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15
Q

Signs of Occlusion include

A

choking; noisy and irregular respiration’s ; decreased oxygen saturation ; blue dusk color

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16
Q

Maintaining a Patent Airway: Primary Consideration

A

Necessary to maintain ventilation, oxygenation

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17
Q

Maintaining a Patent Airway: Provide

A

supplemental oxygen as needed

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18
Q

Maintaining a Patent Airway: Assess breathing by

A

placing hand near face to feel movement of air

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19
Q

Maintaining a Patent Airway: Keep head of bed

A

elavated 15-30 degrees unless contraindicated

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20
Q

Maintaining a Patent Airway: May require

A

sunctioning

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21
Q

Maintaining a Patent Airway: If vomiting occurs,

A

turn patient to side

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22
Q

Maintaining Cardiovascular Stability: To monitor cardiovascular stability, the nurse assesses the patients level of

A

consciousnes

Vital Signs

Cardiac Rhythm

Skin Temperature, Color, and Moisture

Urine Output

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23
Q

Maintaining Cardiovascular Stability: Primary cardiovascular complications seen in PACU include

A

hypotension and shock

Hemorrhage

Hypertension

Dysrhythmias

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24
Q

Hypotension can result from

A

blood loss, hypoventilation, position changes, pooling of blood, or side effects of medications

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25
Q

If amount of blood loss exceeds ____, replacement is usually indicated

A

500 mL

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26
Q

A systolic blood pressure less than ____ is usually considered immediately reportable

A

90 mmHg

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27
Q

A previously stable blood pressure hat shows a downward trend of ___ at each 15-minunte reading should also be reported

A

5 mmHg

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28
Q

Maintaining Cardiovascular Stability: The clasic signs of hypovolemic shock are

A

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

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29
Q

Maintaining Cardiovascular Stability: Hypovolemic Shock can be avoided largely by

A

timely administration of IV fluids, blood, blood products and medications that elevate blood pressure

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30
Q

Maintaining Cardiovascular Stability: Primary intervention for hypovolemic shock is

A

volume replacement, with an infusion of lacated Ringer solution, 0.9% NaCl solution, colloids, or blood compoennt therapy

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31
Q

Maintaining Cardiovascular Stability: What is usually monitored to provide information on the patients repiratory and cardiovascular status

A

Respiratory Rate, Pulse Rate, Blood Pressure, Blood Oxygen Concentration, Urinary Output, and Level of Consciousness

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32
Q

Pt with Hemorrhage presents with Hypotension;

A

Rapid, Thready Pulse;

Disorientation;

REstlessness

oliguria

Cold, Pale Skin

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33
Q

Early phase of shock will manifest in feels of

A

apprehension, decreased CO, and vascular resistance

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34
Q

In hemorrhage, the patient will feel

A

cold and may experience tinnitus

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35
Q

Lab values for hemorrhage may show

A

sharp drop in hemoglobin and hematocrit levels

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36
Q

Primary Hemorrhage characteristic

A

Hemorrhage occurs at the time of surgery

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37
Q

Intermediary Hemorrhagecharacteristic

A

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

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38
Q

SEcondayr Hemorrhage characteristic

A

Hemorrhage may occur sometime after surgeyr if a suture slips because a blood vessel was not securely tied

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39
Q

Capillary Hemorrhage Characteristic

A

Hemorrhage is characterized by slow, general ooze

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40
Q

Venous Hemorrhage Characeristic

A

Darkly colored blood flows quickly

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41
Q

Arterial Hemorrhage Characteristic

A

Blood is bright red and appears in spurts with each heart bit

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42
Q

Evident Hemorrhage Characteristic

A

Hemorrhage is on the surface and can be seen

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43
Q

Concealed Hemorrhage Characteristic

A

Hemorrhage is in a body cavity and cnanot be seen

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44
Q

Hypertension is common in the

A

immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention

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45
Q

Dysrhythmias are associated with

A

electrolyte imbalance , altered respiratory function, pain, hypothermia, sstress, and anesthetic agents

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46
Q

Opioid analgesic medications are given mostly by

A

IV in the PACU

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47
Q

IV Opioids provide

A

immediate pain relief and are short acting, this minimzing the potential for drug interactions or prolonged respiratory depression

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48
Q

Relieving Pain and AxietY: Assess

A

patient comfort

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49
Q

Relieving Pain and AxietY: Control of

A

environment: quiet, low lights, noise level

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50
Q

Relieving Pain and AxietY: family visit,

A

dealling with family anxiety

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51
Q

Alternative techniques to contrtol Postoperative Nausea and Vomiting ?

A

Deep Breathing

Aromatherapy`

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52
Q

Patients remains in the PACU until

A

fully recovered form the anesthetic agent. Indicators include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level

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53
Q

Aldrete Scores is used to determine

A

patients general condiiton and readiness for transfer form the PACU

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54
Q

Aldrete score is usually between

A

7-10 before discharge

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55
Q

Discharge Preparation: Patient and caregiver are informed about

A

expected outcomes and immediate postoperative changes anticipated

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56
Q

Discharge Preparation: Provide

A

written, verbal instructions regarding follow-up care, complications, wound care, activity, medications, diet

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57
Q

Discharge Preparation: Give prescriptions and phone numbers ; discuss

A

actions to take if complications occur

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58
Q

Discharge Preparation: Patients are not to

A

drive home or be discharged to home alone. Sedation, anesthesia may cloud memory, jugement, affect ability

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59
Q

Continuing and TRansitional Care: TRansitional nurse assesses

A

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

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60
Q

Continuing and TRansitional Care: Nursing interventions may include

A

changing surgical dressings, monitoring the patency of a drianage system, or administering medications

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61
Q

During the first 24 hours after surgery, nursing care of the hospitalized patient on the medical-surgical unit involves

A

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

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62
Q

In the initial hours after admission to the clinic unit, what are the primary concerns?

A

Adequate Ventilation

Hemodynamic Stability

Incisional Pain

Surgical Site Integrity

N/V

Neurologic Status

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63
Q

Nursing Management After Surgery: The Pulse Rate, Blood Pressure, and Respiration Rate are recorded at least every

A

15 minutes for the first hour, and every 30 minutes for the next 2 hours

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64
Q

Nursing Management After Surgery: Temperature is monitored every

A

4 hours for the first 24 hours

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65
Q

Assessment of the hospitalized postoperative patient includes

A

monitoring vital signs and completing a review of systems upon the patietns arrival to the clinical unit

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66
Q

Assessment: REspiratory status is important because

A

pulmonary complications are among the most frequent and serious problems encountered by teh surgical patient

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67
Q

Assessment: Why is Flash Pulmonary Edema a possible complication

A

This occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive presure

68
Q

Assessment: Signs and Symptoms of Flash Pulmonary Edema

A

Agitation, Tachypnea, Tachycardia, Decreased Pulse Oximetry REadings

Frothy Pink Sputum

Crackles on Auscultation

69
Q

Hospitalized Patient Recovering From Surgery Nursing Diagnosis

A

Risk for Ineffective Airway Clearance

Acute Pain

Decreased CO

Activity Intolerance

Inpaired Skin Integrity

Ineffective Thermoregulation

70
Q

Hospitalized Patient Recovering From Surgery Potential Complications

A

Pulmonary Infection / Hypopxia

VTE, DVT, PE

Hematoma

Infection

Wound Dehiscence or Evisceration

71
Q

Hospitalized Patient Recovering From Surgery: Major goals inlcude

A

optimal respiratory function, relief of pain, optimal cardiovascular function

Increased Activity olerance

Unimpaired Wound Healing

Maintenance of Body Temperature

Maintenance of Nutritional Balance

72
Q

Preventing Respiratory Complications: What combines to put the patient at risk for respiratory complications, particular atelectasis (alveolar collapse; incomplete expansion of the lung)

A

REspiratory depressive effects of opioid medications

Decreased lung expansion secondary to pain

Decreased mobility

73
Q

Preventing Respiratory Complications: Atelectasis reamins a risk for the patient who is

A

not moving well or ambulating or who is not performing dddeep breathing and coughing exercises or using an incentive spirometere

74
Q

Preventing Respiratory Complications: Signs and Symptoms include

A

Decreased Breath Sounds
Crackles
Cough

75
Q

Preventing Respiratory Complications: Pneumonia is characterized by

A

chills and fever
Tachycardia
Tachypnea

76
Q

Preventing Respiratory Complications: How does Hypostatic Pulmonary Congestion occur?

A

Caused by a weakened cardiovascular system that permits stagnation of secretiosn at lung bases , occurs in oldedr patients who are not mobilized efficitely

77
Q

Preventing Respiratory Complications: Symptoms of Hypostatic Pulmonary Congestion?

A

Symptoms Vague. Slight elevation of temperature, pulse and respiratory rate as well as cough

78
Q

Preventing Respiratory Complications: Physical Examination for Hypostatic Pulmonary Congestion reveals

A

dullness and crackles at the base of the lungs. If it progresses , it may be fatal

79
Q

Preventing Respiratory Complications: Types of Hypoxemia that can affect postoperative patietns are

A

subacute and episodic

80
Q

Preventing Respiratory Complications: Subacute Hypoexmia is a

A

constant low level of oxygen saturation when breahting appers normal

81
Q

Preventing Respiratory Complications: Episodic Hypoxemia develops

A

suddenly, and the patient may be at risk for cerebral dysfunction, myocardiac ischemia, and cardiac arrest

82
Q

Preventing Respiratory Complications: Risk for Hypoxemia is increased in patietns who have undergone

A

major surgery, particularly abdominal, are obese, or have preexisting pulmonary problems

83
Q

Preventing Respiratory Complications: Hypoxemia is detected by

A

pulse oximetry, which measures blood oxygen saturation

84
Q

Preventing Respiratory Complications: Factors that affect the accuracy of pulse oximetry readings include

A

cold extremities, tremors, atrial fibrillation, arylic nails, and blue or black nail polish

85
Q

Preventing Respiratory Complications: Crackles indicate

A

static pulmonary secretions that need to be mobilized by coughing and deep-breathing exercises

86
Q

Preventing Respiratory Complications: To clear secretions and prevent pneumonia, nurse encourages the patient to

A

turn frequently, take deep breaths, cough, and use the incentive spirometer at least every 2 hours

87
Q

Preventing Respiratory Complications: Pulmonary exercises should begin as ssoon as

A

the patient arrives on the clinical unit and continue until the patietn is discharged

88
Q

Preventing Respiratory Complications: Taking several deep breaths helps

A

expel residual anesthetic agents, mobilize secretions, and prevent aelectasis

89
Q

Preventing Respiratory Complications: Analgesic agents are given to permit

A

more effectice coughing and oxygen is given as prescribed to prevent or relieve hypoxia

90
Q

Preventing Respiratory Complications: To encourage lung expansion, the patient is encouraged to

A

yawn or take sustained maximal inspirations to create a negative intrrathoracic pressure

91
Q

Preventing Respiratory Complications: Coughing is contraindicated in patients who have

A

head injuried or have undergone intracarnial surgery, eye surgery, or plastic surgery

92
Q

Preventing Respiratory Complications: Early ambulation increases

A

metabolism and pulmonary aeration and in general improves all body functions

93
Q

Relieving Pain: Intesnse pain stimulates

A

the stress response, which adversely affects teh cardiac and immune systems

94
Q

Relieving Pain: When pain impulses are transmitted, both

A

muscle tension and local vasoconstriction increase, further stimulating pain receptors

95
Q

Relieving Pain: The nurse assesses the effectiveness of the medication periodically, beginning

A

30 minutes after administration or sooner if the medication is being delivered by patient-controlled analgesia (PCA)

96
Q

Opiod Analgesic Medication: What appraoch is more effective at relieving pain?

A

The preventing appraoch, rather than PRN appraoch

97
Q

What is teh Preventive Approach?

A

The medication is given at prescribed intervals rather than when the pain becomes severe or unbearable

98
Q

What is PCA?

A

Patient-Controlled Analgesia

99
Q

What are the two requirements for PCA?

A

They are understanding of the need to self-dose and the physical ability to self-dose

100
Q

PCA Promotes

A

Patient Participation In Care

Eliminates Delayed Administration

Maintains Therapeutic Drug Level

Enables Patient to Move and Turn and Breath with Less Pain

101
Q

Epidural infusions are used with caution in chest procedures because

A

the analgesic may ascent along the spinal cord and affect respiration

102
Q

Intrapleural anesthesia involves the

A

administration of a local anesthetic by a catheter between teh parietal and visceral pleura. Provides sensory anesthesia without affected motor function .

103
Q

Intrapleural Anesthesia allows more

A

effective coughing and deep breathing in condiitons such as cholecysectomy, renal surgery, adn rib fractures

104
Q

What is used in the epidural infusion?

A

Locl Opioid or combination anesthetic

105
Q

For pain that is difficult to control, a ___ may be used

A

Subcutaneous pain management system

106
Q

What happens with a subcutaneous pain management system?

A

Nylon catheter is inserted at the site of the affected area. Catheter attached to a pump that delivers a continuous amount of local anesthetic

107
Q

Other Pain Relief Measures: Nonpharmacologic measures include

A

Guided imagery, music, and implementation of healing touch have been successful clinical adjuncts used to decreased pain and anxiety

108
Q

Promoting Cardiac Output: IV Fluid replacement may be prescribed for up to

A

24 hours after surgery or until the patient is stable and tolerating oral fluids

109
Q

Promoting Cardiac Output: Close Montioring is indicated to detect and correect conditions such as

A

fluid volume deficit, altered tissue perfusion, and decreased cardiac output

110
Q

Promoting Cardiac Output: Some patients are at risk for fluid volume excess secondary to

A

existing cardiovascular or renal disease , advanded age, or other factors

111
Q

Promoting Cardiac Output: Nursing Management includes

A

assessing the patency of the IV lines and ensuring tha tthe correct fluids are given at teh prescribed place

112
Q

Promoting Cardiac Output: If patient has an indwelling urinary catheter, hourly outputs are

A

monitored and should not be less than 0.5 mL/kg/hr

113
Q

Promoting Cardiac Output: Oliguria is reported

A

immediately

114
Q

Promoting Cardiac Output: What other things are monitored?

A

Elecrolyte Levels

Hemoglobin

Hematocrit Levels

115
Q

Promoting Cardiac Output: Decreased hemoglobin and hematocrit levels can indicate

A

blood loss or dilution of circulaitng volume by IV fluids

116
Q

Promoting Cardiac Output: If dilution is contributing ot the decreased levels , the hemoglobin and hematocrit will

A

rise as the tress response abates and fluids are mobilized nd excreted

117
Q

Promoting Cardiac Output: Venous Stasis from dehydration, immobility, and pressure on leg veins during surgery put patient at risk for

A

VTE

118
Q

Encouraing Activity: Early ambulation has a

A

significant effect on recovery and the prevention of complications (atectasis, hypostatic pneumonia, GI discomort, circulatory problems

119
Q

Encouraing Activity: Ambulation reduces

A

postoperative abdominal distention by increasing GI tract and abdominal wall tone and stimulating peristalsis

120
Q

Encouraing Activity: Early ambulation prevents

A

stasis of blood, and thromboembolic evens occur less frequently

121
Q

Encouraing Activity: Examples of bed exercises that improve circulation?

A

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

122
Q

Caring for Surgical Drains: What are surgical drains?

A

Tubes that exit the peri-incisional area, either into a portable wound suction devide (closed) or into the dressing (open)

123
Q

Caring for Surgical Drains: Principle involved with drains is to

A

To allow the escape of fluids that could otherwise serve as a culture medium fo rbacteria

124
Q

Caring for Surgical Drains: In portable wound usctioning

A

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

125
Q

Caring for Surgical Drains: Types of wound drains include

A

Penrose, HEmovac, and Jackson Pratt Drains

126
Q

Changing the Dressing: Dressing is applied to a wound for the following reaons

A

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

127
Q

Maintaining Normal Body Temperature: Patient is still at risk for

A

malignant hyperthermia and hypothermia

128
Q

Maintaining Normal Body Temperature: Patients who have received anesthesia are susceptible to

A

chills and drafts

129
Q

Maintaining Normal Body Temperature: Treatment includes

A

oxygen administration, adequate hydration, and proper nutrition including glycemic control

130
Q

Maintaining Normal Body Temperature: PAtient is also monitored for

A

cardiac dysrhythmias

131
Q

Maintaining Normal Body Temperature: The risk of hypothermia is greater in

A

older adults and in patietns who wre in the cool OR environment for prolonged periods

132
Q

Managing GI Function and REsuming Nutrition: If risk of vomiting is high due to the nature of surgery, a

A

ng tube is inserted preoperatively and remains in place throughout the surgery adn the immediate postoperative period

133
Q

Managing GI Function and REsuming Nutrition: If hiccupts persist, they may produce

A

considerable distress and serious effects such as vomiting, exhaustion and wound dehiscence

134
Q

Managing GI Function and REsuming Nutrition: Postoperative distention of the abdomen results from

A

the accumulation of gas in the intestinal tract

135
Q

Managing GI Function and REsuming Nutrition: Manipulation of the abdominal organs during surgery may produce a loss of normal peristalsis for

A

24-48 hours

136
Q

Promoting Bowel Movement: REseatch suggests that ____ particuly following laprascopic surgery, can help restore bowel function and prevent paralytic ileus by promoting peristalsis

A

chewing gumq

137
Q

Managing Voiding: What interferes with the perception of bladder fullness adn the urge to void?

A

Anesthetics, Anticholinergic agents, adn opioids

138
Q

Promoting Bowel Movement: _____ may increase the likelihood of retention secondary to pain

A

Abdominal, pelvic, and hip surgery

139
Q

Promoting Bowel Movement: Patient is expected to void within

A

8 hourus after surgery

140
Q

Promoting Bowel Movement: If Patient has not voided in that time, what is performed to check for urinary retention?

A

Untrasound Bladder Scan or Bladder Ultrasonography

141
Q

Promoting Bowel Movement: Postvoid residual urine may be assessed by using either

A

straight catheterization or an ultrasound bladderscanner

142
Q

Promoting Bowel Movement: Intermittent catherterization may be prescribed every

A

4-6 hours until the patietn can void spontaneously and postvoid is less than 50 mL

143
Q

Assessment after surgical procedure for the extremities incllude

A

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

144
Q

Managing Potential Complications: What is a treatment for patients at high risk for VTE?

A

Prophylactic treatment .

Low-molecular-weight or low-dose heparin and low-dose warfarin are other anticoagulants that may be used

145
Q

Managing Potential Complications: The stress response that is initiated by surgery inhibits the

A

thrombolytic system, resulting in blood hypercoagulability

146
Q

Managing Potential Complications: What adds to the risk of thrombosis formation?

A

Dehydration, low CO, blood pooling in the extremities and bed rest

147
Q

Managing Potential Complications: Factors that can increase risk of DVT?

A

Thrombosis

Mlignancy

TRauma

Obesity

Indwelling Venous CAtheters

And Estrogen Use

148
Q

Managing Potential Complications: First symptom of DVT?

A

Pain or cramp in the calf although many patients are asymptomatic

149
Q

Managing Potential Complications: DVT initial pain and tenderness may be followed by

A

painful swelling of the enitre leg, often accompained by fever, chills, and diaphoresis

150
Q

Possible Respiratory Complciations?

A

Atelectasis

Pneumonia

Pulmonary Embolism

Aspiration

151
Q

Possible CArdiovascular Complications

A

Shock

Thrombophlebitis

152
Q

Possible Neurologic Complications

A

Delirium, Stroke

153
Q

Possible Skin/Wound Complications

A

Breakdown, infection, dehiscence, evisceration, delayed healing, hemorrhage, hematoma

154
Q

Possible GI Complications

A

Constipation

Paralytic Ileus

Bowel Obstruction

155
Q

Possible Urinary COmplications

A

Acute Urine retention

Urinary Tract Infection

156
Q

Possible Functional Complications

A

Weakness

Fatigue

Functional Decline

157
Q

Possible Thromboembolic Complcations

A

Deep Vein Thrombosis

Pulmonary Embolism

158
Q

What is a Hematoma?

A

A clot formation within the wound

159
Q

How is a largge Hematoma treateed?

A

Sutures removed by the surgeon, clot evacuated, and wound is lightly packed with gauze

160
Q

Managing Potential Complications: Wound infection may not be evident until at least

A

postoperative day 5

161
Q

Managing Potential Complications: Signs and Symptoms of Wound Infection include

A

Increase Pulse Rate and Temperature

elevated WBC

Wound Swelling, Warmth, Tenderness, or Discharge

162
Q

What does Serous fluid look like?

A

Thin, clear, watery plasma

163
Q

what does sanguineous fluid look like?

A

bloody draineage, seen in deep partial-thickness

164
Q

What does serosanguineous look like

A

Thin, watery, pale red to pink plasma with red blood cels

165
Q

What does purulent fluid look like?

A

Thick, opaque drianage that is tan, yellow, green or brown

166
Q

A meal should contain

A

high-protein that provide sufficient fiber, calories, and vitamins

NRSG 102: Med Surg 1 (52 decks)

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