NRSG258 - 6

Question 1

Patient Controlled Analgesia -PCA

Answer 1

• Used to manage post operative and chronic pain
• PCA pump permits the patient to self administer bolus doses of opioid analgesic medication.
• The pump then delivers a pre-set amount of medication (usually Intravenously but can be via SC or epidural route)
• Can have a continuous infusion (basal rate or background) and still allow additional bolus doses of medication
• The pump is an electronically controlled by a timing device. (lock out) time prevents/reduces risk of overdose.
• PCA use usually means patients require less pain medication and achieve better pain relief than those treated by the standard prn plan

Question 2

Redivac drain - Indication

Answer 2

To allow the escape of blood or serous fluid that can otherwise serve as a culture medium for bacteria.

With closed drain systems the use of gentle, constant suction enhances drainage of these fluids and collapses the skin flaps against the underlying tissue thus removing dead space.

Question 3

Redivac Drain - Nursing responsibilities

Answer 3

• Measure output FBC – amount, colour, consistency
• Check suction patency
• Check surgical dressing for bloody ooze.
• Excessive drainage should be reported
• Change drain when full (aseptic technique)

Question 4

Tonsillectomy

Answer 4

• Tonsils are two small glands in the back of throat
• Help to deal with infections, particularly in childhood
• An operation to remove tonsils called tonsillectomy

Question 5

Adenoidectomy

Answer 5

• Adenoids are small lumps of soft tissue found at the back of nose
• The surgical remove of adenoids are adenoidectomy
• Tonsillectomy and adenoidectomy done together is commonly referred as T&As.

Question 6

T&As - Signs & Symptoms

Answer 6

• Swelling of the tonsils
• Redder than normal tonsils
• A white or yellow coating on the tonsils
• Snorring and difficult in breathing
• Fever
• Recurrent ear infections

Question 7

T&As - Common treatment

Answer 7

• Throat cultures to identify infections in the throat
• X-ray to visualize the size of the adenoids
• Blood test: infection
• Surgical procedure

Question 8

T&As - Nursing interventions

Answer 8

• Pain management
• humidified O2
• maintain oral intake
• mouth care
• avoid activities
• post-operative review

Question 9

Family Centred Care

Answer 9

• Empowers patients and their families and fosters independence
• Supports family care-giving and decision-making
• Respects patient and families’ choices and their values, beliefs and cultural backgrounds
• Builds on individual and family strengths
• Involves patients and their families in the planning, delivery and evaluation of health care services.

Question 10

How can we practice family centred care?

Answer 10

• Believing and trusting parents/carers and patients – they are the experts in their child/themselves.
• Introducing yourself each time you walk into the room and explaining what it is you’re going to do.
• Listening to patients and families and giving them an opportunity to discuss any of their questions, anxieties or concerns.
• Discussing which aspects of care the patient or family would like to provide, where it is safe to do so. Not every patient or parent/carer will want to contribute to patient care in hospital so this needs to be discussed with each patient/family.

Question 11

core concepts of family Centred Care

Answer 11

Dignity and respect
Information sharing
Participation
Collaboration

Question 12

family Centred Care - Dignity and respect

Answer 12

Staff listen to and respect patient and family perspectives and choices.

Patient and family knowledge, values, beliefs and cultural backgrounds are incorporated into the planning and delivery of care.

Question 13

family Centred Care - Information sharing

Answer 13

Staff communicate and share complete, objective and accurate information with patients and families in ways that are supportive and useful.

Patients and families receive timely, complete and accurate information in order to effectively participate in care and decision-making.

Question 14

family Centred Care - Participation

Answer 14

Patients and families participate in care and decision making at the level they choose, with the support and encouragement of staff.

Question 15

family Centred Care - Collaboration

Answer 15

Patients, families and staff collaborate in policy and program development, implementation and evaluation, in health care facility design, in professional education, as well as in the delivery of care.

Question 16

PACU assessments

Answer 16

• Monitor patient and be aware of GA and intra op risks for a 4yr old
• Assess airway breathing and circulation
• Obtain baseline vital signs, including O2 sats
• Assess neurological status, including level of consciousness and movement of extremities.
• Assess level of pain- last dose, type and current pain rating
• Assess colour and appearance of skin
• Assess urinary status, bladder distention or urge to void
• Position for airway maintenance, comfort and
• Check IV infusion-site, fluid type, orders, patency and amount
• Assess for nausea and vomiting-available emesis bowl and tissues
• Check emotional state of child
• Check presence of family member or carer.
• Check all orders Have the child drink adequate cool fluids or chew gum, as this reduces spasms in the muscles surrounding the throat.
• Give paracetamol syrup as prescribed
• Apply an ice collar around the child’s neck if tolerated

Tonsillectomy and adenoidectomy increase risk of vomiting by 30-40 %
-> could be related to anaesthetic • Following tonsillectomy it is important for the nurse to closely monitor nausea and vomiting in the paediatric patient. • -> High incidence of vomiting due to the irritation of pharynx and stomach from blood

The exact incidence of common post-operative complications in children is unknown.
Most common is post operative nausea and vomiting followed by respiratory complications leading to hypoxia.

• Cardiac complications are less likely in children without associated congenital cardiac anomaly
• Post operative shivering, agitation and delirum are seen more often in children anaesthetised with newer inhalation agents ie. Sevoflurance
• Urinary retention could be influenced by anaesthetic drugs

Question 17

Respiratory Differences between adult and child

Answer 17

A

• longer and wider airways
• Small tonsils and adenoids
• Larger oral cavity and smaller tongue ratio
• Epiglottis small
• Larger airways decrease oedema and swelling
• More rigid muscles in neck

C

• Shorter and narrower airways
• Larger tonsils and adenoids
• Smaller mouth cavity and larger tongue
• Epiglottis long and swells easily
• Increased risk of oedema
• Neck not rigid and more easily flexed causing occlusion

Question 18

Renal System

Answer 18

* AKA urinary system or urinary tract
Consists of the
* kidneys
* ureters
* bladder
* urethra

Purpose:

• Eliminate waste from the body
• Regulate blood volume
• Regulate blood pressure
• Control levels of electrolytes and metabolites
• Regulate blood pH

Question 19

Common Post-Operative T & A Symptoms

Answer 19

• Throat pain: Duration 2 weeks
• Dehydration
• Ear pain: Duration 2 weeks ·
• Halitosis ·
• Weight loss ·
• Fever: low grade ·
• Bleeding: A very small amount of bleeding can occur between 6-8 days after surgery, when the scab sloughs off. This is typically a very small amount and stops in 2-3 minutes.

Question 20

Post-Operative T & A Bleed Facts

Answer 20

• Occurs in 2-5% of patients
• Primary bleed occurs less than 24 hours postoperatively ·
• Secondary bleed occurs greater than 24 hours postoperatively, usually 5-10 days, but seen up to 14 days ·
• Majority are self-limiting · Sudden and severe hemorrhage is a known post-operative complication that may result in death.
• Post-op T & A bleed may be a true surgical emergency and requires immediate ENT consultation and potential OR intervention.
• Remain vigilant for an apparent small, self-limiting bleed (‘heralding bleed’) that precedes a larger bleed within the next 24 hours.

Question 21

TREATMENT for Post-Operative T & A Bleed

Answer 21

• Keep patient upright and encourage them to spit blood into a bowl; document quantity · Suction should be available if needed Monitoring ·
• Vital signs per nursing protocol · Cardiorespiratory monitoring for actively bleeding patients:
• Airway management as needed · Rehydration - insert one large-bore IV catheters ·
• NPO ·
• IV fluid resuscitation ·
• Consider O-negative blood as needed
• IV analgesia (no NSAIDs); titrate narcotic dose up as many patients have obstructive sleep apnea (OSA) and are at a risk for airway obstruction ·
• ENT CONSULTATION:
  All patients who complain of fresh bleeding from the throat whether or not this has stopped and/or the presence of a clot, require ENT consultation