Module 1: Part 3 Flashcards
During the first 24 hours after surgery, nursing care of the hospitalized patient consists of:
- Helping the patient recover from the effects of
anesthesia - Frequently assessing the patient’s physiologic status
- Monitoring for complications
- Managing pain
- Successful management of the therapeutic regimen
In the initial hours after admission to the clinical unit, what are the primary concerns for a pt?
(know 4)
- Adequate ventilation
- Hemodynamic stability
- Incisional pain
- Surgical site integrity
- Nausea and vomiting
- Neurologic status
- Spontaneous voiding
For the 1st hour post-surgery, how often are BP, HR and RR taken?
Every 15 min
For the 2 hours following the 1st hour post-surgery, how often are BP, HR, and RR taken?
Every 30 min
For the 1st 24 hours how often is the temp monitored?
Every 4 hours
Why should you monitor for airway patency and any signs of laryngeal edema post-surg
Because pulmonary complications are among the most frequent and serious problems encountered by the surgical patient
What are some factors that may cause shallow and rapid respirations in the post-surg pt?
(Know 3)
- Pain
- Constricting dressings
- Gastric dilation
- Abdominal distention
- Obesity
What factors may cause noisy breathing?
May be due to obstruction by secretions or the tongue
What causes flash pulmonary edema?
Protein and fluid accumulate in the alveoli, unrelated to elevated pulmonary artery occlusive pressure
What are some signs and symptoms of flash pulmonary edema?
- Tachypnea
- Tachycardia
- Decreased pulse oximetry readings
- Frothy pink sputum
- Crackles
What might be indicated by a pt with post-operative restlessness or a change in their mental state?
May be related to anxiety, pain, or medications. May also be a symptom of oxygen deficit, urinary retention, or hemorrhage
What are the major goals for postop pts?
Know 4
- Optimal respiratory function
- Relief of pain
- Optimal cardiovascular function
- Increased activity tolerance
- Unimpaired wound healing
- Maintenance of body temperature
- Maintenance of nutritional balance
What is atelectasis?
Alveolar collapse, incomplete expansion of the lung
Which postop pt are at a higher risk for atelectasis?
- Pts who are not moving well or ambulating
- Not performing deep-breathing and coughing
exercises - Not using an incentive spirometer
Signs and symptoms of atelectasis?
- Decreased breath sounds over the affected area
- Crackles
- Cough
What are some charateristics of PNA?
- Chills and fever
- Tachycardia
- Tachypnea
- Cough may or may not be present and may or may not
be productive
Hypostatic pulmonary congestion more frequently occurs in which pts?
In older pts who are not mobilized effectively
Signs and symptoms of hypostatic pulmonary congestion
- Slight elevation of temperature, HR, and RR
- Cough
- Crackles at the base of the lungs
What is subacute hypoxemia?
A constant low level of oxygen saturation when breathing appears normal
What is episodic hypoxemia?
Develops suddenly, pt may be at risk for cerebral dysfunction, myocardial ischemia, and cardiac arrest
What are 3 factors that increase the risk for hypoxemia?
- Pts who have undergone major surgery (particularly
abdominal) - Obese pts
- Pts with pre-existing pulmonary problems
To clear secretions and prevent pneumonia, what should the nurse encourage the pt to do?
- Turn frequently
- Take deep breaths
- Cough
- Use the incentive spirometer
How often should pts use the incentive spirometer?
At least every hour
Coughing is contraindicated in which pts?
- Those with head injuries or who have undergone
intracranial surgery (because of the risk for increasing
intracranial pressure) - Pts who have undergone eye surgery (because of the
risk for increasing intraocular pressure) - Pts who had plastic surgery (because of the risk for
increasing tension on delicate tissues).
What affect does stress have on the body’s ability to form blood clots?
The hypothalamic stress response results in an increase in blood viscosity and platelet aggregation, increasing the risk of thrombosis and PE
What is the goal for pt controlled analgesia (PCA)?
Pain prevention rather than sporadic pain control
What are teh 2 requirements for PCA?
- An understanding of the need to self-dose
2. The physical ability to self-dose
Why are epidural infusions used with caution in chest procedures?
Because the analgesic may ascend along the spinal cord and affect respiration
How does intrapleural anesthesia affect breathing/coughing/etc?
Allows for more effective coughing and deep breathing in conditions such as cholecystectomy, renal surgery, and rib fractures in which pain in the thoracic region would interfere with these exercises
Is wound drainage included in an input/output record?
Yes
If your pt has an indwelling urinary catheter, how often should you be checking it?
Every hour
What mL should the pt be voiding every hour?
Greater than 30mL/hr, anything less is reported
What mL should the pt be voiding every 8 hours?
Greater than 240mL/hr, anything less is reported
What might dec hgb and hct levels indicate?
Blood loss or dilution of circulating volume by IV fluids
Venous stasis from dehydration, immobility, and pressure on leg veins during surgery put the patient at risk for:
DVT
What can the pt do to prevent thrombosis?
- Leg exercises and frequent position changes
- Avoid positions that compromise venous return (raising
the bed’s knee gatch, pillow under the knees, sitting
for long periods, and dangling the legs) - Venous return is promoted by antiembolism stockings
and early ambulation
How does ambulation reduce postoperative abdominal distention?
By increasing GI tract and abdominal wall tone and stimulating peristalsis
How does early ambulation affect pain?
Pain is often decreased with early ambulation
What is orthostatic hypotension?
An abnormal drop in blood pressure that occurs as the patient changes from a supine to a standing position
How is orthostatic hypotension detected?
BP is taken in the supine position, after the patient sits up, again after the patient stands, and 2 to 3 minutes later
For a safe discharge home, what do pts need to be able to do mobility-wise?
- Be able to ambulate a functional distance
- Get in and out of bed unassisted
- Be independent with toileting
What is a benefit of wound drains?
They allow the escape of fluids that could otherwise serve as a culture medium for bacteria
In what situation are nurses permitted to touch a wound dressing with ungloved hands?
Never, because of the danger of transmitting pathogenic organisms
Why does the tape used for dressing a wound need to be flexible?
Because some wounds become edematous after having been dressed, causing considerable tension on the tape. If the tape is not flexible, the stretching bandage will also cause a shear injury to the skin
In what situations is a nasogastric tube inserted?
- If risk of vomiting is high due to the nature of surgery
- If postoperative distention is anticipated
- If a patient who has food in their stomach requires
emergency surgery
Normal peristalsis may be lost for 24-48 hours after surgery, why is that?
Because of the manipulation of the abdm organ during surgery
After major abdominal surgery, distention may be avoided by:
- Having the patient turn frequently
- Exercise
- Ambulate as early as possible
How long does an NG tube inserted before surgery remain in place?
Until full peristaltic activity has resumed
If the abdomen is not distended and bowel sounds are present, but the pt does not have a bowel movement by the second or third postoperative day, what should you do?
Notify the physician so that a laxative can be ordered
What affect do anesthetics, anticholinergic agents, and opioids have on the bladder?
They interfere with the perception of bladder fullness and the urge to void and inhibit the ability to initiate voiding and completely empty the bladder
How soon after surgery is the pt expected to void?
8 hours
Which is preferred and why:
Intermittent or indwelling catheterization
Intermittent because the risk of infct is lower
Why should a bedpan be warm when given to a pt for voiding?
A cold bedpan will cause automatic tightening of muscles, making it much more difficult to void
What should the nurse do after a pt has finished voiding?
They should make sure that the bladder is completely empty by palpating or using a bladder scanner
How often is intermittent catheterization done?
Every 4-6 hours until the post-void residual volume is less than 100mL
Why do post-surg assessments include having the pt move their hands and feet through a full range of motion?
Because this will verify that no nerve, circulatory, or other damage has been done to the extremities
What are some post-surg complications that a pt may experience?
- DVT
- Hematoma
- Infct
- Wound dehiscence and evisceration
What are some threats to recovery that may be anticipated in older pts?
(Know 4)
- Delirium
- Pneumonia
- Decline in functional ability
- Exacerbation of comorbid conditions
- Pressure ulcers
- Decreased oral intake
- GI disturbance
- Falls
What are some factors that determine whether a patient is at risk for delirium?
(Know 3)
- Age
- History of alcohol abuse
- Preoperative cognitive function
- Physical function
- Serum chemistry
- Type of surgery
What would be the result of inhibiting the cytochrome P450 enzyme system?
This system is largely involved in opioid metabolism, so it’s inhibition would result in a prolonged effect
What qualifies a drug to be classified as “pregnancy category 3” ?
Medication that has shown adverse effects on fetuses in animal studies
Does morphine have a low or high ability to bind to proteins?
Low protein binding ability (40%)
12% of the unchanged morphine product can be eliminated via _____.
Urine
What is the half life of morphine?
Between 1.5-2 hours
For a pt who is opioid naive, what perameters should be placed on their PCA?
- 1-mg to 2-mg bolus
- Six-minute lock-out interval
- Self-administration dose of 1.5 mg to 3 mg per hour.
For a pr who is opioid tolerant, what parameters should be placed on their PCA?
- 1-mg to 3-mg bolus
- Six-minute lock-out interval
- Self-administration dose of 3 mg to 10 mg per hour
What is an absolute contraindication for using morphine? Relative contraindications?
Absolute: A pre-existing allergy
Relative: Acute asthma or significant upper airway obstruction
Why should morphine be avoided in pregnant or breastfeeding women?
Because morphine can cross the placental barrier and has been found in breast milk
What are the most serious adverse effects of morphine?
Respiratory in nature, leading to hypoventilation and hypercapnia
What are some other adverse effects of morphine?
- CNS depression
- Psychosis
- Constipation
- Euphoria
- Oliguria
T or F:
Hydromorphone is not a pregnancy category C medication
F, it is
What is the avg half life of hydromorphone (IV)?
2.5 hours, there is extensive tissue uptake
For PCA, how is hydromorphone usually ordered?
- 0.1 mg to 0.2 mg
- Five to 15-minute lock-out interval
- A four-hour limit may be set at between 4 mg and 6 mg
Why must the perioperative nurse exercise care when administering the product to patients who have respiratory depression or status asthmaticus?
Because hypoxia may result
What is an absolute contraindication to hydromorphone use? A relative contraindication?
Absolute: Known hypersensitivity
Relative: GI obstruction (this product decreases peristalsis)
What are some adverse effects of hydromorphone?
- Respiratory depression
- Hypotension
- Flushing
- Constipation
- Urticaria (hives)
IS fentanyl a pregnancy category C med?
Yes
Why does fentanyl have such a rapid onset?
Because of it’s ability to quickly cross the blood brain barrier
Large doses of fentanyl can produce _____
Apnea
Adverse affects of fentanyl?
- Hypoventilation
- Bradycardia
- Sedation
Is meperidine a pregnancy category C med?
Yes
Which has a longer duration:
Meperidine or morphine?
Morphine.
Meperidine has more kappa affinity and peaks faster but also dissipates faster, resulting in a shorter duration
What is the half life of meperidine?
3-8 hours in healthy individuals
What might a typical PCA order for meperidine look like?
- Initial infusion of 10 mg
- Range of 1 mg to 5 mg per incremental dose
- Lock-out interval can range from six to 10 minutes
The metabolism of meperidine result in the formation of what bioactive metabolite?
Normeperidine, which has an extended half-life elimination period of up to 20 hours
Meperidine may also aggravate pre-existing ________ disorders
Convulsive
The use of meperidine with another CNS agents can have significantly serious interactions. What are some of the adverse effects?
- Respiratory depression
- Hypotension
- Sedation
- Coma
- Death
Do obese pts report having more or less pain?
More
What effect does an increased weight have on joints?
Causes degeneration to happen more quickly
More body fat = higher risk of developing ________ _______
Metabolic syndrome
Fibromyalgia is characterized by..?
…chronic widespread musculoskeletal
pain on both sides of the body.
What is the link between obesity and fibromyalgia?
Obesity contributes to the continued presence of FM and increases the severity of the disorder. (research ongoing)
How if the protein binding ability of drugs affected by obesity?
There is a decreased ability for drugs to bind to proteins
Why might morphine and fentanyl not be ideal for obese pts?
Morphine may worsen any pre-existing resp conditions and fentanyl is a lipid soluble drug
Why do obese pts require less local anesthetic while having epidural catheters placed?
Because they have decreased spinal fluid volume
