Exam 7 Post op Flashcards
PACU
Post
Anestassia
Care
Unit aka Recovery
Stages of Post-op
Phase I-immediately after surgery
Phase II-no close monitoring
Phase III-prep for discharge
PACU environment
Clean, quiet, no permanent walls
Nursing Management
Provide care until anesthesia wears off
Pt is oriented, stable vs, and not bleeding
Constantly assessing
Primary Consideration
Maintain a patent airway
How to maintain a patent airway
Assess by putting hand near face/nose
Bed elevated 15-30 degrees
May require suction
If vomit, turn on left side
Signs of Hypovolemic shock
Pale Cool Moist skin Clammy Rapid respirations Low BP Concentrated urine Rapid/weak/thready pulse
Cyanosis
Classification of Hemorrhage
Primary Intermediary Secondary Capillary/Venous/Arterial Evident/Concealed
Primary Hemorrhage
Occurs at time of surgery
Intermediary Hemorrhage
1st few hours after surgery when BP come up and may push clot loose
Secondary Hemorrhage
After surgery if suture slips
Capillary Hemorrhage
Slow general ooze
Venous Hemorrhage
Dark colored bubbles out quickly
Arterial Hemorrhage
Bright red and spurts with heartbeat
Evident Hemorrhage
On surface and can be seen
Concealed hemorrhage
Can not be seen. in body cavity
How to monitor cardiovascular stability
Monitor vs/LOC/rhythm/skin/ s&s of shock
Assess all IV lines
Monitor for hemorrhage
Monitor for hypertension/dyssrhythmia/hypoxia/hypothermia
Ways to help with pain and anxiety
Assess pt comfort
Control environment
Admin pain med
Family visits
Controlling N/V
Immediately turn on left side
Help control without sedating
Medications used to control N/V
Metoclopramide (Reglan) Prochlorperazine (compazine) Promethazine (Phenergan) Dimenhydrinate (Dramamine) Hydroxyzine (Vistaril, Atarax) Scopolamine (Transderm-Scop) Ondansetron (Zofran)
Dealing with Elderly
Monitor carefully & frequently Inc chance of confusion/delirium Causes for confusion - hypoxia,pain,hypotension,hypoglycemia, & fluid loss Assess meds Ensure hydration Reorient
When are you ready to discharge
Stable VS Orientation x3 Uncompromised pulmonary Adequate O2 sat Urine output 30 ml No N/V Minimum Pain
Pars Evaluation Guide
Scored when enter PACU q 15 min Activity (2 1 0) move on command/spontaneously Resp (2 1 0) TDBC Circulation (2 1 0) BP normal Consciousness (2 1 0) fully awake O2 sat (2 1 0) 92% with room air
Must be 8-10 to discharge
Assessment for Post op Complication
Assess VS q 15 min Monitor q 4 hours Assess airway/respirations Assess cardiovascular status Assess pain
What should the assessment include?
O2 IV Tubes VS Circulation General Airway/Suction Position resp/O2 sat/ breath sounds surgical wound LOC Neuro functioning spinal anes (extremities) dressing/drains/drainage I&O iv site/ iv fluids comfort pain standard precautions
Responsibilities of PACU nurse
Review important info and the baseline assessment
Assessments/Interventions
Provide report & transfer pt to next location
Communicate with pt
What is reported when transferring?
What was done in PACU
demographic data types/amt of med
medical dx meds for pain
procedure done if pt has voided
co-morbid condition what info pt/family got
allergies unexpected intra-op events
est. blood loss
Equipment needed
Bed (surgical) IV equipment Emesis Basin Pads Blankets Drainage receptors holders O2 Monitoring devices Post op charting
Floor nurse responsibilities
Bed position Spirometer Make connections Bowel Sounds Airway Family VS TCDB Surgical Dsg. I&O/Safety Pain Oral care Activity
Ambulatory surgery
Written instructions Complication to report phone numbers & who to call Prescriptions to fill Rules & how long to follow them
Types of surgical drains
Penrose-open
Jackson-Pratt-closed
Hemovac-closed
Wound healing mechanisms
First-intention-suture
Second-intention-granulation
Third-intention-granulation –> suture
Factors that affect healing
Age Meds Edema Overactivity Handling of tissue Systemic disorders Hemorrhage Immunosuppressed state Hypovolemia Wound stressors Nutrition Foreign Bodies Oxygen deficit
Purpose of post op dressing
Provide healing environment Absorb drainage Splint or immobilize the wound Protect from injury & contamination Promote hemostasis Promote pt's physical & mental comfort
Changing post op dressing
Surgeon changes 1st Get dressing materials Wash hands Maintain sterile technique Assess wound Apply dressing & taping methods Include pt response & teaching Document findings & teaching
Dehiscence
Parial/Complete seperation of outer layer of wound.
Causes: poor suturing, distention, excess vomiting/coughing, dehydration, and infection
Evisceration
Total separation of layers & protrusion of organs/viscera thru open wound.
