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nurs5082 devep mursing practice > L5 postop > Flashcards

L5 postop Flashcards

1
Q

what r the post-op care included

A

Care in recovery Care in the ward Care on discharge

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2
Q

Care in Recovery, what r the priority

A

– Anaesthetist gives report to admitting recovery nurse – Surgeon documents procedure and specific instructions – Priority in recovery is: 1. monitoring and management of vital functions 2. Assessingwhetherthepatient is safe to return to ward/unit 3. Any concerns then alert the patients surgical team/ anaesthetist

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3
Q

Approach to assessment in any stage of post-operative care

A

– Airway: Patent/compromised – Breathing: rate, depth, SpO2 blood gas analysis, auscultation of chest – Circulation: HR, BP, capillary refill, pallor, urination, any signs of bleeding, – Disability: neurological signs, Glasgow Coma Scale, AVPU – Exposure: check patient head to toe – Fluids: fluid regime/balance – Glucose

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4
Q

Postoperative complications immediately after surgery

A

Alterations to: Respiratory function Cardiovascular function Neurological function Pain & discomfort Thermoregulation Nausea & Vomiting

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5
Q

respiration alteration in

A

Alterations in: – Patency: airway obstructions – Oxygenation (hypoxaemia) – Disruption to gas exchange (atelectasis, aspiration, pneumonia, pulmonary oedema) – Hypoventilation – Bronchospasm: smooth muscle tone increases, closing small airways

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6
Q

what r the assessment for respiration alteration, and management

A

Assessment – Rate & quality of respirations – SpO2 peripheral capillary oxygen saturation – Auscultate breath sounds in all fields Management – Airway adjunct to maintain airway – Sit upright – Oxygen therapy (check Drs orders) aids removal of anaesthetic & meets increased oxygen demand

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7
Q

Signs & Symptoms of Respiratory Alterations

A
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8
Q

Cardiovascular Function: Alterations of Cardiac Output

A

CO = Stroke Volume x HR

– Pre-load:

– Hypovolaemia (haemorrhage)

– Vasodilation (septic shock, some anaesthetic agents cause vasodilation)

– Contractility:
– Cardiacconduction – Ventricularfailure

– Afterload:
– Hypertension

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9
Q

Cardiovascular Alterations

A

Hypertension

Hypotension (vasodilation from anaesthesia or haemorrhage

Arryhthmias (abnormal heart rhythm)- Arrhythmias associated with electrolyte imbalance, myocardial infarction, altered respiratory function, anaesthesia

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10
Q

Signs & Symptoms of Cardiovascular Alteration

A
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11
Q

Neurological Alterations

A

Alterations:

– Altered level of consciousness (LOC)

– Stroke: ischaemic or haemorhagic

– Emboli: air or blood

– Hypoxia

– Until patient is fully awake they will be unable to maintain a safe environment for themselves

– Consider bed rails
– Disturbed sensory perception

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12
Q

Signs & Symptoms Neurological Function

A
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13
Q

Nausea & Vomiting

A

– Nausea & vomiting may be caused from anaesthetic agents or narcotics

– Delayed gastric emptying

– Slowed peristalsis

Management:

Anti-emetic medications (e.g. metoclopromide, ondansetron)

Intravenous fluids if unable to take fluid orally

Physical assessment for signs of dehydration

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14
Q

Thermoregulation

A

– Hypothermia: core temperature below 36 C

– Cold operating theatre

– Heat loss due to exposure of body organs

– Anaesthesia can lead to vasodilation

– Malignant hyperthermia

– Complications of hypothermia include compromise of:

– Immune system

– Bleeding

– Delayed drug metabolism

Management

– Monitor temperature

– Warming blankets

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15
Q

Other, post op care. urinary, fluid, dressing, drainage, pain, explain

A

– Urinary (beware that patients may experience urinary retention)

– Fluid balance

– Assess surgical dressings for bleeding, distension to local area

– Assess drainage from surgical drains (if applicable)

– Assess level of pain

  • Explain everything to the patient, orientate to environment, explain procedure is now complete etc.
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16
Q

Transfer of patient from recovery

A

– ISBAR handover, or similar

– On receiving the patient in the ward area undertake an ABCDEFG assessment

– Check the medical records to ensure that you understand the procedure undertaken and any special directions

– Make your patient comfortable by considering:

– Nausea&vomiting

– Thermoregulation

– Pain

– Re-orientationtotheir surroundings

17
Q

Post-operative complications following transfer to ward/unit

A

Alterations to:
Respiratory function Cardiovascular function Neurological function Pain & discomfort Thermoregulation Nausea & Vomiting

First 24 hours post surgery require more close monitoring

18
Q

Respiratory Function

A

– Atelectasis & Pneumonia can occur following any surgery, particularly abdominal surgery

– Absence of deep breathing due to pain, or sedentary reclined position and lack of coughing leads to development of mucus plugs in the lungs

– Smoking increases the risk How will we know?

– Monitoring vital signs: respiratory rate, peripheral saturation (SpO2), auscultation of chest, capillary refill

19
Q

Respiratory nursing care

A

– To avoid complications of atelectasis and pneumonia:

– Encourage regular deep breathing

– Encourage regular coughing

– Teach patient how to diaphragmatically breath

– Incentive spirometer

– Provide regular analgesia

– Splinting to reduce pain of coughing/breathing

– Regular re-positioning

– Teach these techniques pre-

operatively

– Mobilisation

– Engage assistance of physiotherapist

20
Q

Cardiovascular

A

– Risk of arrythmias – dependent on surgery and other risk factors, patient may require cardiac monitoring

– Risk of reduction in cardiac output (anything that affects pre-load, afterload, contractility)

– Bleeding, may only become obvious once transferred to ward

– Systemic infection, likely to become obvious after several days (if not present pre- operatively)

21
Q

Cardiovascular (Fluid balance)

A

– Fluid & electrolyte imbalance

– Fluid retention

– Fluid overload

– Fluid deficit

– Hypokalaemia (low Potassium) Assessment:

Syncope – may indicate decreased cardiac output

Oedema

Dehydration (dry mucous membranes, dry skin, vital signs)

Vital signs

22
Q

Prevention of VTE

A

– Early mobilisation

– Lower leg exercises

– Anti-embolism stockings

– Pneumatic leg compression devices

– Anti-coagulants (enoxaparin)

– Regular repositioning of patients who are not conscious or cannot move themselves

  • Physiotherapy
  • Regular monitoring for swelling, redness, tenderness to legs, particularly calf area
  • Consider risk factors: - Smoking
  • Surgery (causes hypercoagulation)
  • Contraceptive pill
  • Previous VTE
23
Q

Gastrointestinal Alterations

A

– Nausea & vomiting

– Imbalanced nutrition (nil by mouth pre-surgery), increased nutritional requirements post-surgery

– Assess for active bowel sounds & flatus (in all four quadrants) – if patient received abdominal surgery they cannot eat/drink until bowel sounds present

– Non-bowel surgery: patient can eat & drink when their gag reflex is intact

24
Q

Gastrointestinal Care

A

– Patient may have nasogastric tube (NG) to decompress stomach

– Intravenous fluid may be prescribed to maintain hydration

– Specific instructions from surgical team may include clear fluids only, or light diet, or Nil by Mouth (NBM)

– Early ambulation may help stimulate the bowel

– Encourage expulsion of flatus

25
Q

Bowel obstruction types of obstruction

A

Mechanical obstruction, caused by:

Adhesions (sm. Bowel)
Hernia
Strictures

Intussusception

Cancer (colon)

Diverticular disease

Vascular obstructions:

Emboli and atherosclerosis of the mesenteric arteries

– Non-mechanical: Paralytic ileus, lack of intestinal peristalsis and bowel sounds (in all four quadrants)

– Occurs to some degree after any abdominal surgery

– Signs & symptoms vary:

– Bowelsoundsmaybeabsent,or high pitched bowel sounds above the area of obstruction

26
Q

nurse care for bowel obstruction

A

Nursing management:

– Monitoringofbowelsounds,NG output, IV fluid input, keeping patient NBM

– Analgesia, anti-emetics

– Oralcare–moistenmouth,lip moisturising, brush teeth.

27
Q

Infection (local) signs and symptoms

A

Signs:

– Redness (vasodilation & increased blood flow)

– Heat (vasodilation)

– Swelling (vasodilation)

– Loss of function (pain & swelling)

Symptoms:

– Pain (nociceptor stimulation)

– Loss of function

Local infection can become systemic (sepsis/Systemic Inflammatory Response Syndrome)

28
Q

Systemic infection signs and symptoms

A

Signs:

– Raised temperature (>37.2 C)

– Increased HR

– ReductioninBP&hypotension

– Increased respiratory rate

– Rigors

– Febrileconvulsions(commonin paediatrics)

– Sweaty(diaphoretic)

Symptoms:

– Feelinghot – Achyjoints – Restlessness – Pain

29
Q

Infection & nursing interventions

A

– If signs of infection, either local or systemic arise, alert surgical team

– High fever: cooling measures: cold compress, fan

– Antipyretic medication (paracetamol, ibuprofen)

– Antibiotics (if prescribed)

– Adequate hydration (IV therapy or oral intake)

– Regular monitoring of vital signs according to severity of condition

– Specific wound dressings

30
Q

Pressure Area Care

A

– Prolonged sedentary positions put pressure on the skin and reduce blood flow to that area

– Post-operative patients are at particular risk of pressure sores due to anesthetic, nutrition, pain, immobility.

– Pressure sores are graded in terms of severity

– Common sites of pressure sores:

– Occiput (particularly in ventilated patients)

– Elbows

– Ischial tuberosity’s

– Heals

31
Q

Constipation and nursing care

A

– Low urine output may be expected in first 24 hours, min/hour 0.5mls/Kg

– Increased aldosterone & ADH from stress of surgery

– Fluid restriction pre-surgery

– Fluid loss during surgery

– Patient may have a urinary catheter insitu

– Retention

– Loss of sensation e.g. epidural

– Anaesthetic medications may interfere with ability to initiate voiding

– Pain may inhibit bladder emptying

– Recumbent position

– Renal ischaemia

32
Q

Pain Theories

A

– Gate-control Theory: pain impulses pass through when a gate is open and are blocked when a gate is closed (Melzack & Wall 1965)

– Otherlessrecenttheories:

• Specificity • Intensity • Pattern

33
Q

mechanism of pain

A

Mechanism of pain

– Nociception: physiological mechanism by which information about tissue damage is communicated to the brain:

– Transduction

– Transmission

– Perception

– Modulation

– A delta fibres (sharp pain)

– Cfibres(aching,throbbing pain)

– A beta fibres sensitive to vibration, movement, not pain

34
Q

Assessment of Pain

A

definition of pain:‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

pain assessment:

– P: Provoking factors – Movement, rest

– Q: Quality – Burning,stabbing,crushing

– R: Radiation – Movementofpain

– S: Severity of pain – Mild to severe

– T: Time of onset/ frequency – Various pain scales for adults & children

– Visual analogue scales (VAS)

35
Q

Dimensions of Pain: Biopsychosocial Model of Pain

A

– Acute vs. chronic

– Physiological

– Affective: emotional response

– Cognitive: beliefs attitudes

– Behavioural: grimacing, irritability, gender and pain

– Sociocultural: families & carers experience, culture and response to pain

Different types of pain:

– Nociceptive (ongoing stimulation of nociceptors)

– Neuropathic pain (numbing, hot, burning)

– Acute pain

– Chronic pain

– Intractable pan

– Referred pain

– Somatic pain (arising from skin, muscles, bones, localised)

– Visceral pain (poorly localised)

36
Q

Pain Treatment

A

– Continuous analgesia

– Epiduralinfusion:analgesia delivered to epidural space, direct effect on opioid receptors in spinal cord

– Intravenousinfusion

– Intermittent analgesia

– Oral medication

– Patient controlled analgesia (IV)

37
Q

Other forms of analgesia

A

– General anaesthetic

– Nerve blocks (local anaesthetic)

– Epidural (local anaesthetic + opioid)

– Oral medication

– Non-steroidal anti-inflammatory – Opioid
– Non-salicylate (paracetamol)

– Adjuvant drugs for pain: e.gAntidepressants, anti-seizure medication

– Topical medication – Opioid – NSAIDgel/cream

– Most medications have side effects that are important to be aware of, for example:

– Opioids:
• Respiratory depression • Sedation
• Constipation
• Nausea
• Pruritis (itching)

38
Q

Non-pharmacological pain strategies

A

– Massage

– Repositioning

– Transcutaneous electrical nerve stimulation (TENS)

– Acupuncture

– Heat therapy

– Cold Therapy

– Distraction

– Hypnosis

– Relaxation

39
Q

psychological care

A

Psychological Care

– Dependent on result of surgery, anxiety & depression may arise

– Altered body image

– Consider alcohol withdrawal in

pre and post op phase

– If patient has mood change consider:

– Sideeffectfrommedication

– Dehydration

– Poornutrition

– Expectations ill aligned

– Reportanyunusualbehaviour or affect to surgical team

nurs5082 devep mursing practice (8 decks)

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