Lecture 13: Post-Op Care Flashcards
what does -ectomy mean + example
meaning: excision or removal of
ex: appendectomy and cholecystectomy
what does -lysis mean + example
meaning: destruction of
ex: electrolysis and lysis of adhesions
what does -orrhaphy mean + example
meaning: repair or suture of
ex: herniorrhaphy
what does -oscopy mean + examples
meaning: looking into
ex: endoscopy, colonoscopy, laraproscopy
what does -ostomy mean + examples
meaning: creation of opening into
ex: colostomy
what is -otomy meaning and example
meaning: cutting into or incision of
ex: tracheotomy
what does -plasty mean + examples
meaning: repair or reconstruction of
exx: mammoplasty and rhinoplasty
what is the post-op journey (4 parts)
- operating room
- PACU (post anesthesia care unit)
- surgical ward (same day surgery)
- discharged from hospital
what are the 5 things to monitor in PACU
- ABC’s: respiratory and circulatory function
- pain
- temperature
- surgical site
- client’s response to the reversal of anesthetic
when are patients moved from PACU to surgical ward
once PACU discharge criteria is met:
- PACU nurse gives a verbal report to surgical nurse and escorts pt to floor
what is lateral recovery
‘recovery position’ while they regain consciousness
Postanaesthesia Discharge Criteria
- Pt awake for baseline
- vital signs stable
- no excess bleeding or drainage
- no resp depression
- oxygen saturation >90%
- report given
what happens if pt is an ambulatory surgery in PACU, how are they released
can go home if they meet discharge criteria with PACU nurse discharge teaching instructions
ambulatory surgery discharge criteria
- all PACU discharge criteria met
- no IV opioids for last 30 minutes
- minimal nausea and vomiting
- voided (if appropriate to procedures)
- able to ambulate if age appropriate or not contraindicated
- responsible adult present to accompany pt
- written discharge instructions given and understood
what to check for LOC in post-op assessment
are they awake?
- alert
- voice
- pain
- unresponsive
are they drowsy or confused
what are the 3 nursing post operative assessment
- LOC
- Vital signs + Pain
- Head-to-Toe
whats the pain assessment
OPQRSTUV
what’s an important thing to assess in post-op assessment
surgical drains and the surgical incision site
what are some orders the surgical team may write out for a pt that the nurse would have to do in post-op? (4)
- IV’s
- Diet orders
- Input/output monitoring
- Vitals
what is important to remember about pain management in post-op
keep it continuous
- when was their last dose? how effective? has pain changed in location or severity?
- alert pt to call you if pain increases
what should you check before leaving the patient in room (3)
- check for support person in room
- call bell in reach
- provide emesis basin, ice chips/water (if allowed), offer a warm blanket
what are the key topics of discharge teaching (7)
- new meds
- diet restrictions
- activity restrictions
- wound care/drains/bathing
- concerning sympt: go to ER or call surgeons to office
- follow-up appt w surgical team
- home care referrals
what’s important for the communication of discharge teaching
give the pt a chance to ask questions during ur teaching
what are the 3 most common respiratory complications in the PACU
- airway obstruction
- hypoxemia
- hypoventilation
1.what is airway obstruction? 2. what are potential clues? 3. what are interventions for it?
- mechanical blockage to the airway
- decreasing o2 sat, absent respirations
- lateral ‘recovery position’ for PACU pts while recovering consciousness. head tilt, chin lift.
1.what is hypoxemia?
2. what are potential clues? 3. what are interventions for it?
- inadequate oxygenation of blood
- decreasing o2 sat, abnormal RR
- applying supplemental O2 therapy (nasal prongs, etc), deep breathing
1.what is hypoventilation?
2. what are potential clues? 3. what are interventions for it?
- decreased resps
- low RR, decreased O2 sat
- support ventilation, encourage deep breathing
2 most common respiratory complications on surgical unit
- atelectasis
- pneumonia
- what is atelectasis?
- risk factors
- pt clues
- prevention/intervention
- complete/partial collapse of lung or lung segment when alveoli become deflated
- heavy smoker, pulmonary disease, pulmonary infection, drying of mucous membranes from: intubation anesthetic or dehydration, mucous plugs from: hypoventilation or lying position
- decreased o2 sat, decreased breath sounds, crackles auscultated
- deep breathing/coughing, incentive spirometer, position change q1-2 hrs, ambulation, pain management, oral hydration
what are 2 key ideas about atelectasis
- increased bronchial secretions post-operatively
- decreased lung volume
- what is pneumonia
- pt clues
- interventions
- infection of lungs
- cough w sputum, decreased breath sounds, fever
- o2 therapy, treatment of pathogen, ambulation, deep breathing/coughing
3 most common PACU cardiovascular complications
- hypotension
- hypertension
- dysrhythmias
- what is hypotension
- pt clues
- interventions
- low bp
- bp measurement, dizziness, LOC, check pain, etc…
- intravenous fluid therapy, RBC’s
- what is hypertension
- pt clues
- intervention
- high bp
- bp measurement, low temp
- manage pain, manage anxiety, relieve bladder distention, manage hypothermia
- what is dysrhythmias
- pt clues
- intervention
- non-sinus cardiac rhythm
- dizziness, chest palpitations/pain, pre-existing cardiac conditions
- correct hypokalemia, manage hypoxemia and hypercarbia
if you see pt deteriorating who do u call
surgeon
2 common causes of cardiovascular complications in a surgical ward
- electrolyte imbalance
- fluid imbalance
- what is electrolyte imbalance
- causes/risk factors
- abnormal K, Na levels
- loss of K thru emesis/diarrhea and not replaced, chronic cardiac disease, chronic renal disease, advanced age
- what is fluid imbalance?
- causes/risk factors
- hypovolemia or hypervolemia
- IV fluids given too quickly or too slowly, stress response releases aldosterone = Na and fluid retention, fluid loss during surgery (blood) and post-op (emesis, urine, drainage)
what are 2 key points to remember about surgical ward cardiovascular problems
- abnormal K levels can impact cardiac function
- hypovolemia can cause syncope (decreased cardiac output) common in geriatric pts
what is virchow’s triad (damage to the vessel lining)
- stasis (alteration in blood flow)
- hypercoagulability (changes in the constituents of the blood)
- vascular endothelial injury
what is stasis
venous return from extremities is aided by muscular contraction and valves. post-op, pt are less mobile
what is vascular endothelial injury
damage occurs w bloodwork, IV access, and central venous access post-op
what is hypercoagulability
dehydration, cancer and surgery causes changes in the blood constituents making thrombus formation more likely
what is venous thromboembolism
- CVS complications
- thrombus forms in association w inflammation of vein; commonly the legs (DVT)
- can dislodge and move into lungs = pulmonary embolism (EMERGENCY)
- what is DVT
- pt clues
- thrombus in vasculature of the extremities
- unilateral swelling, unilateral pain, history of surgery/immobilization
- what is pulmonary embolism
- pt clues
- thrombus in the vasculature of lungs
- tachypnea, tachycardia, thoracic pain
what is non-pharmacological venous thromboembolism
- early mobilization
- exercises for pts that are bedrest
- elastic compression stockings: decrease distal calf vein thrombosis
- intermittent compression devices (automatic sleeve that applies intermittent pressure to legs)
what are 2 high risk post-op complications
- virchow’s triad
- venous thromboembolism
what is intermittent compression device (ICD)
- pts w moderate to very high risk for DVT/PE
- must be applied correctly
- must be worn continuously
- not used when pt has an active DVT
pharmacological treatments of venous thromboembolism
anticoagulants
- prevent DVT + PE formation in high-risk pts
- treat DVT & PE by preventing new clot development, spread of clot, embolization, SC or orally, may require blood work for CBC, INR, aPITT
what are the VTE pharmacological options (5)
- warfarin coumadin
- dalteparin (low molec heparin)
- unfractionated heparin
- dabigatran
- rivaroxaban
warfarin
route:
mech:
monitoring:
antidote:
route: PO
mech: vitamin K antagonist
monitoring: frequent INR
antidote: vitamin K, octaplex, fresh frozen plasma
dosing based on INR levels
dalteparin (LMWH)
route:
mech:
monitoring:
antidote:
route: SQ, q24hrs
mech: indirect thrombin, inhibitor
monitoring: CBC
antidote: protamine
effective prevention/treatment of DVT
does not require anticoagulant monitoring and dose adjustment
unfractionated heparin
route:
mech:
monitoring:
antidote:
route: SQ q12hrs, IV continuous infusion
mech: indirect thrombin inhibitor
monitoring: CBC, aPITT
antidote: protamine
dabigatran (pradax)
route:
mech:
monitoring:
antidote:
route: SC
mech: direct thrombin inhibitor
monitoring: aPITT
antidote: n/a supportive care w RBC’s, fresh frozen plasma
rivaroxaban (xarelto)
route:
mech:
monitoring:
antidote:
route: PO
mech: factor Xa inhibitors
monitoring: CBC
antidote: n/a supportive care w RBC’s, fresh frozen plasma
what are the coagulation studies and how do you interpret the results
name the parameter and SI units for each (4)
- international normalized ratio (INR): 0.81-1.2
- platelet count (thrombocytes): 150-400 x10^9/L
- prothrombin time (PT): 11-12.5 sec
- partial thromboplastin time (PTT): 28-35 sec
2 PACU/surgical GI complications
- nausea and vomiting
- nutritional imbalance
what would you use to adjust your heparin infusion rate
heparin infusion order/table
- what are risk factors/causes of nausea and vomiting
- treatment
- female w history of motion sickness, certain anesthetics/opioids, less the 50 yrs, prolonged or abdominal surgery, paralytic ileus
- antiemetics (ondansetron), aromatherapy (alc swab/peppermint), IV fluid therapy
- what are risk factors/causes of nutritional imbalance
- treatment
- temp diet limitations post surgery, paralytic ileus may delay starting oral intake
- early pt mobilization to encourage flatus, resume normal diet when appropriate, if severe: total parenteral nutrition may be considered
severe emesis can lead to…
fluid and electrolyte balances
- what is paralytic ileus
- risk factors/causes
- pt clues
- treatment
- impaired intestinal motility for several days post-op
- abdominal/GI surgery, surgery
- distended abdomen, abdominal pain, diminished bowel sounds, poor appetite, nausea/vomiting
- encourage mobilization, if severe: nasogastric tube (bowel rest/decompression), monitor for flatus/stool
what are special post-op diets
- low sodium
- cardiac
- diabetic
- renal
what are 2 urinary tract complication
- low urinary output
- urinary retention
- what is low urine output?
- causes/risk factors
- treatment
- low urinary output (<30 ml/hr)
- stress response post-op (aldosterone, ADH secretion), fluid restriction pre-surgery, fluid loss in OR, drain output/NG output, diaphoresis
- accurate intake/output measurements, IV fluid replacement, increasing oral intake
what may oliguria indicate
inadequate renal perfusion and be a risk for renal failure and acute kidney injury
what is the MINIMUM output of urine
after 48 hrs it should be…
what is low urine output
30 mL/hr
after 48 hrs it should be: 1500-2500 mL
low urine output: 500-700mL
- what is urinary retention
- causes/risk factors
- pt clues
- treatment
- inability to fully empty bladder or pass urine
- urinary surgeries, uncontrolled pain, anesthesia, supine position, meds
- low urine output, distended bladder upon palpation, hypertension
- facilitate voiding (commode vs bedpan, running water, increased oral intake), bladder scan, foley catheter to relieve distension
aunuria
no urine
oliguria
low urine
polyuria
lots of urine
temp changes up to 12 hrs after surgery
temp:
possible causes:
interventions/prevention:
temp: hypothermia to 36 celsius
possible causes: effects of anesthesia, body heat loss in surgical exposure
interventions/prevention: assess temp q4hr, encourage airway clearance, warm blankets
temp changes in first 24-48 hrs after surgery
temp:
possible causes:
interventions/prevention:
temp: elevation to 38 celsius, or above
possible causes: inflammatory response to surgical stress, atelectasis
interventions/prevention: assess temp q4hr, encourage airway clearance
temp changes in 3rd day and later after surgery
temp:
possible causes:
interventions/prevention:
temp: elevation above 37.7 celsius
possible causes: wound infection, urinary infection, respiratory infection, phlebitis
interventions/prevention: aseptic wound care and IV site, if febrile: chest x-ray, cultures of wound/urine/blood, monitor leukocyte level
2 psychological complications post-op
- anxiety and depression
- confusion and delirium
treatment of anxiety and depression in post-op
therapeutic supportive listening
social work referral for support
treatment of confusion and delirium post-op
determine etiology of confusion/delirium and treat
