L2 Perioperative Nursing Flashcards
- Pre-op checking & Assesment
- Pre-op nursing intervention with rationales
- Post-op complication and nursing care
- Post-op pain management & nursing care
Pre-op assesment liver and kidney
Assessment
Hepatic & renal function
1. Impairment of liver
Care:
1. Meaure liver function
2. Assess history of liver disease
3. Advise to stop alcohol abuse
- Impairment of kidney
Care: - Monitor fluid balance / renal function
- Assess history of urinary & renal disease
Pre op assesment of nutrition & denition
Assessment of nutrition
1. Iden factors: malnutrition / obesity / weight loss
2. Loss of electrolyte and fluid caustion
Denition assesment
1. Aware of decay teeth
Care:
1. asses any tooth problem & refer to dentist
2. Educate proper oral & teeth care
3. Remove denture before surgery
Pre op for medication history
Obtain medical history
- prevent contraindication during surgery
Document all used medicine
OTC preparation / herbal agent
Pre-op assesment- respi
Care:
1. Asses & monitor vital sign
2. Asses the age related factor that may affect respi function
3. Educate deep breathing & coughing exercise
4.advice for quit smoking
Pre op Assesment- cardi
- Assess & monitor vital sign, heart sound, ECG 心電圖
- Assess skin colour,chest pain, dypsnea
- Arrange PCI percutaneous coronary intervention if needed
- Adjust medication e.g. aspirin if needed according to doctor’s order
Pre-op assesment- endocrine
Assess endocrine disease e.g. DM / hyperthyroidism
Pre-op Assesment for immune function
Asses patient for substances that cause allergic effect e.g. latex, blood product transfusion
-) test: blood test, ecg,
Pre-op assesment- psychosocial
Psychological distress
1. Direct influence body functioning
2. Affect ability to learn
3. Influence recovery process, affect amount of anesthesia
Care:
1. Perform assessment to patient’s anxiety / coping ability
2. Verify expectation of the surgery: realistic expectation to reduce anxiety when post-op
3. Provide help by active listening
4. Provide accurate info
5. Facilitate sleeping the night before surgery: manage stress
6. Respect cient’s value, culture to prevent misunderstanding
Post-op care
1.Consciousness
2. Respiratory
3. Haemodynamic
4. Body temp
5. Nutrition & hydration
6, pain management
7. Wound
8. Drain
9. Elimination
10. Comfort & safety
11. Psychological
Post op complication
- Hypovolemic
- Hemorrhage
- Dysrhythmias
- Hypopharyngeal obstruction
- Hypothermia
- Atelectasis
- Pneumonia
- Deep vein thrombosis
- Pulmonary embolism
- Nausea & vomiting
- Constipation
- Intestinal obstruction
- Wound infection
- Wound dehiscence
- Depression
Post-op care: consciousness
Care:
1. Assess awareness by GCS
2. Attention to high risk e.g. elderly group
Post-op care- respiratory
Care:
1. Provide oxygen therapy if needed
2. Assess pattern of breathe, pulse
3. Special care to patient with ventilator support
(Ensure the function of ventilator)
4. Promote breathing and coughing exercise for lung expansion
Post op care- haemodynamic
Care:
1. Monitor blood pressure / pulse rate
-) haemodynamic stable
- Monitor skin colour, skin condition for assessing perfusion status
- Administrate IV fluid if needed
-) to maintain adequate blood circulation
Post-op temperature monitoring
Care:
1. Monitor temperature regularly
-) prevent hyperthermia
2. Provide water progressively to prevent aspiration
3. Record I/O
4. Provide warming device e.g. forced-air warming blank
5. Cover the patient
6. Limit exposure
7. Appropriate room temperature
Post-op pain management
Inadequate pain management leads to
1. Slower healing
2. Impaired mobility
3. Gastric stress: nausea, vomiting
4. Breathing complication: impaired deep breathing
Care
1. Perform pain Assesment (PQRST / facial expression /
2. Monitor vital sign to detect physical change
3. Educate for proper supporting wound site
4. Med: NSAID / paracetamol
4. Avoid overuse or underuse of pain control medicine
Pain management medicine
NSAIDS ( ibuprofen)
Opioid (tramadol)
IV paracetamol
Patient controlled analgesia
( fentanyl, morphine)
Post-op care- wound management
Care:
1. Assess wound condition and inform surgeon for any abnormality
- Apply aseptic technique
- Educate patient about wound care & advice to support the wound when coughing
Post-op drain care
1. Assess characteristics of drain
2. Ensure drainage system is well-functioning wit vacuum
3. Inform surgeon for abnormality e.g.massive amount of drainage
Post-op elimination care
Care:
1. Assess client’s urination, any difficulty
2. Foley catheter insertion if urine retention
3. Monitor urine output
4. Assess bowel pattern & bowel sound
Assess urine, any difficulty?
Provide urine catheter if have difficulty in voiding
Assess urin output
Assess bowel pateern & bowel sound
Post-op comfort care
1. Provide enough blanket
2. Provide fall precaution
Post-op psychological care
1. Assess emotional issue
2. Encourage family involvment
3. Refer peer support
Post-op complication- hypovolemic shock
低血溶性休克
Cause:
Severe hypovolemia from fluid deficit or hemorrhage
S/s:
Cool skin
Rapid breathing
Rapid pulse
Low blood pressure
Blurred vision
Dizziness
Weakness
Care:
monitor vital sign
Supine position with raised leg
Give blood transfusion to replace the lost blood
Give ivf as indicated
Give oxygen as indicated to maintain resspiration
Post-op complication- hemorrhage
Cause:
Injury
S/s
Bleeding from wound
Swelling
Increased pain
Nursing care
Monitor vital sign
Give blood transfusion to replace lost blood
Give oxygen to maintain respiration
Give medicine to maintain cardiac & renal functioning
Keep monitoring bp / urine output / cvs to monitor improvement
Post-op complication-dysrhythmias (atrial fibrillation)
Cause:
1. Electrolyte imbalance
S/s
1. Irregular heart beat
2. Decreased oxygen saturation
3. Difficulty breathing
4. Chest pain
5. Palpitation (心悸）
Care
1. Monitor vital sign & ECG
2. Give oxygenation to support circulatory system
Hypopharyngeal obstruction
Cause
1. Prolong anaesthesia with muscle relaxant, lower jaw and tongue fall back & block the airway
S/s
1. Noisy & irregular respiration
2. Choking
3. Low oxygen saturation
4. Cyanosis
Care:
1. Monitor sign of obstruction: saturation / skin colour
2. Turn to lateral position if vomit to prevent choking & aspiration
3. Inset oropharyngeal tube to keep patent airway
Post-op complication- Hypothermia
Care
1. Monitor temp regularly
2. Control temperature at 25oc
3. Provide warm blanket to maintain temperature
4. Provide warm infusion to increase body temp
Post-op complication- atelectasis 肺不張
Cause:
Analgesics 止痛藥
Prolong bed rest
S/s
1. Dyspnea
2. Tachycardia
3. Raised pulse
4. Decreased oxygen saturation
Care:
1. Assess respiratory status
2. Encourage deep breathing to enhance lung expansion
3. Refer to PT for breathing exercise
Post-op complications- pneumonia
Cause
Poor breathing cause atelectasis & promote pathogen growth
S/s
Difficult breathing
Tired looking
Rapid pulse
Sputum production
Care:
1. Asses respiratory status
2. Perform suctioning if drainage clearing is needed
3. Encourage deep breathing & coughing exercise
4. Refer to Pt for breathing & coughing exercise
Post-op complications- deep vein thrombosis
Cause:
1. Immobility
2. Prolong bed rest
Forming blood clot in deep vein
S/s
1. Engorged superficial vein in lower limbs
2. Swelling
3. Redness
Care:
1. Encourage mobilization to prevent stasis of blood clot
2. Provide stocking & compression device to prevent emboli
3. Measure circumference of lower limb
Post-op complications- pulmonary embolism
Care:
Same
1. Assess sign of PE
2. Provide oxygen therapy
3. Arrange investigation e.g. CT
Post-op complications- post-op nausea
Cause:
Drug effect of anaesthetic, ingesting food before peristalsis, anxiety
S/s
1. Fatigue
2. Dehydration
3. Abnormal electrolytes
4. Weight loss
5. Abnormal distention
Care
1. Asses amount & frequency of vomit & vomitus
2. Assess underlying reason od nausea
3. Provide pain control
4. Provide small & frequent meal
5. Turn to lateral pose to avoid aspiration when vomit
6. Administrate IVF as prescribed
7. Monitor vital sign
Post-op complications- constipation
Cause:
1, decreased mobility & oral intake
2. Side effects of opioid analgesics
S/s
1. Hard to defecus
2. Dry & small size of stool
3. Abdominaldistention 腸氣
4. Low appetite
Care
1. Assess elimination pattern & sign of constipation e.g. bowel sound, ab distention
2. Encourage fluid & fibre intake
3. Encourage early
4. Administrate laxative as prescribed
Post-op complications- intestinal obstruction
Cause:
Blockage of intestine during surgery
S/s
1. Fewer or no bowel sound
2. Increased gastric output
3. Dilated stool
4. Poor appetite
5. Abdominal pain
Care
1. Assess vital sign
2. Keep fasting to reduce pressure of stomach
3. Monitor hydration status
Post-op complications- wound infection
Cause:
1. Improper aseptic technique
2. Repeatingly exposed wound
S/s
1. Wound pain
2. Purulent discharge
3. Prolong fever
4. Chill & shiver
Care:
1. Assess wound site
2. Proper aseptic technique
3. Refer to wound nurse
4. Educate client for knowledge about wound care
Post-op complication- wound dehiscence 爆開/ evisceration 瀉出嚟
Cause
1. Poor suturing technique
2. Obesity
3. Vigorous coughing
S/s
1. Wound oain
2. Distention on wound site
3. Peritoneal fluid drainage from wound site
Care:
1. Secure wound by covering with wet saline without pressure
2. Monitor vital sign for any ohysical change
3. Prepare for emergency operation
Post-op complication- depression
Cause:
Delay recovery
Changed body image
Physiological response after surgery
S/s
1. Loss of ambition
2. Loss of appetite
3. TeRfulness
4. Rejection
5. Sleeping disorder
Care:
1. Closely observe alter of mood
2. Provide opportunity to express anger & feelings
3. Provide quiet & comfy site to rest
Pre-op preparation
Confirm identification
Check allergy history
Ensure body weight and body height are recorded for calculation of the
dosage of anesthetic medication
Administer the preoperative medication (on call to OT) / bring the
medication to OT (on induction)
Reassess physical and mental state that fit for surgery
Check last food & drink
Check vital signs
Verify the signed consent form (Ensure the completeness and correctness
of the consent form)
Confirm all laboratory and diagnostic test reports are available
Ensure completion of physician’s order for preoperative preparation
Insertion of Foley catheter/ nasogastric tube, Skin preparation,
bowel prep, reconfirm marking site, intravenous lines, blood product
transfusion
Check infectious condition and ensure appropriate precaution measures
(e.g. airborne precautions)
(2) PREOPERATIVE PREPARATION
Record if there is pacemaker (with mode adjusted)/ ICD or metal implant
Record if there is any loose teeth
Remove all property, prostheses, denture, watch, contact lens, hairpin and
clothing and assist to change operative cap and gown; wear anti-embolic
stockings
Leave hearing aid for communication and notify operating room nurse
Label and store client’s valuables in a locked place as per agency’s policy
Ifjewelry is unable to be removed, tape it in place. However, jewelry over
hand and arm must be removed when surgery involve cast application or
mastectomy
Ensure the removal of nail polish and cosmetics to facilitate the assessment of
circulation
Ensure devices bring along to OT, e.g. abduction pillow, sequential compression
device
Inform surgeon and operating room nurse if any abnormal finding or any
changes in client’s condition e.g. fever, unstable haemodynamic status,
hyperglycemia/ hypoglycemia, altered mental state, chest discomfort…)
Ensure site marking is available if necessary
