NUR 118 - Lecture 6 - PeriOp Nursing (Pain) P. 2 Flashcards
What must be assessed before starting diet?
-HCP orders
-Level of consciousness
-Can they swallow
-Do they have a gag reflex
-Is the GI tract functioning
-Do they have nausea
-Are they vomiting
What is the progression of diet?
- NPO Post Operatively, then:
Clear liquid
Full liquid
To prescribed diet
“clear liquids, progress as tolerated”
What are the use of drains?
What are the three drains?
Allows fluids to exit tissue, prevent excess pressure building up
Penrose drain, Jackson Pratt drain, Hemovac
Describe PenRose Drain and nursing responsibilities
Flat flexible LATEX (allergies) tube
Only keep in for a few days
Measure exposed parts to track assessment to assessment
Describe the Jackson Pratt drain and nursing responsibilities
- Bulblike bladder
- Must compress to have suction in device
- ***Empty when half full
- No suction to draw, if full - Assess for more or less drainage, if patient complains
- Check if tube is compressed/kinked
- Attach tubing to clothing to prevent tension
Nursing responsibilities for Hemovac drain
- Measure at intervals, or when needed
- Check drains frequently, full = no suction to drain fluid
- Assess if there’s more or less drainage than previously
- Check if tube is compressed, kinked
Who is the first to change the dressing PostOp?
The surgeon
Difference between Dehiscence and Evisceration
Dehiscence – separation of one or more layers of wound; caused by poor nutrition, obesity, strain on suture line, inadequate closure, infection
Evisceration – total separation of the layers of wound with internal viscera protruding through
What are Nursing Interventions for Dehiscence?
- Maintain bedrest with HOB @ 20 degrees & knees flexed
- Apply binder to prevent evisceration
- Notify provider of occurrence
What are the Nursing Interventions for Evisceration?
- Cover wound w/ sterile towels soaked w/ sterile saline (NO BINDER FOR EVISCERATION)
-Bedrest with knees bent to prevent strain
-HOB 20 degrees
-notify surgeon and prep for surgery
PostOp Complications: Hemorrhage
Signs/Symptoms, interventions for prevention and treatment
External: Dressing saturated sanguineous, increased blood in drains, dependent (underneath) drainage
Internal: Pain, swelling near surgical site, ecchymosis
Vital signs: tachycardia, hypotension
Interventions to prevent: Monitor VS, dressings & drainage
- Patient looks pale
Post Op Complications: Infection
Signs/Symptoms:
Swelling
Redness
Heat
Pain
Fever >100.4
May have increased heart rate
Purulent drainage
Interventions for prevention:
- Monitor s/s of infection
- Monitor v/s
- Sterile technique for dressing change
- Hand hygiene
- Culture if prescribed
Post Op Complications: Thrombophlebitis
Thrombophlebitis - Blood clot and inflammation of vein in leg
- Caused by stasis of blood
Signs/Symptoms: red leg, hot to touch, edematous, aching, cramp
Intervention to prevent: Prevent DVT, compressions, movement, may have heparin
PostOp Complications: Pulmonary Embolism
Thrombus breaks away, travels in circulation to lungs
s/s (signs/symptoms): sudden onset of dyspnea, SOB, chest pain, hypotension, tachycardia, decreased oxygen saturation
Intervention to prevent: Prevent DVT, compressions, movement, may have heparin
PostOp Complications: Respiratory - Pneumonia
Inflammation of alveoli due to infection with bacteria or viruses; alveoli filling with solid material instead of air
Signs/Symptoms -
How should we take the patient’s claim to pain?
Pain is whatever the patient says it is whenever he says he has it
What are three classifications of pain?
Origin, cause, duration
What are the types of pain by Origin?
Cutaneous/superficial - SKIN, sub cutaneous
Deep somatic - ligaments, tendons, nerve, bone, blood vessels (ex: fracture, torn acl, sprain)
Visceral - stimulation deep interval pain receptors (ex: cramps, GI infection, labor)
Radiating/referred - has a start then extends to another area (ex: sciatica, back to leg)
Phantom - PAIN/BURNING/ITCHING IS MISSING EXTREMITY
Psychogenic - ? pain from the mind; no physical cause identified yet; only classified once everything else is ruled out
(ex: stomach pain from anxiety)
Types of Pain Classified by Cause
Nociceptive – pain receptors respond to stimuli that are potentially damaging; regular injury to body tissue
(ex: falling down stairs, getting hit)
Neuropathic – complex, usually chronic, injury to nerves results in repeated pain signals in absence of painful stimuli; nerve injury
(ex: diabetics with nerve pain
Types of Pain Classified by Duration
Acute - rapid onset r/t (related to) injury/surgery; less than 6 months
Chronic - longer than 6 months, interferes with daily living
Intractable - Chronic & highly resistant to relief; needs multiple pain relief methods
List non-pharmacologic interventions for pain
Positioning/Posture
Education/Anticipatory Guidance
Touch- Gentle pressure or massage
Relaxation/Distraction/Music/Pet Therapy
Meditation/Guided imagery
Aromatherapy
Acupuncture/Acupressure
TENS (nerve stimulator)
PENS
Heat/cold treatment
Contralateral stimulation
Progressive muscle relaxation
Hypnosis
Journaling
Humor
Oral sucrose
PQRST for pain
Provoking Factors
Quality
Region & Radiation
Severity
Timing
What are the 4 pain Assessment scales?
When to use them
Numeric Rating Scale: 0-10; have to tell patient 0 is no pain, 10 is worst possible pain
Visual Analog Scale: A horizontal line; “no pain” on left, to “worst pain imaginable” on other side
Wong-Baker Faces Scale - 6 faces; for children, cognitively impaired adults
FLACC Pain Scale: Used for behavioral pain assessment for nonverbal/preverbal patients unable to self-report pain; 2 months old to 7yo
What is an important obstacle towards surgical recovery?
Pt will not be able to participate in surgical recovery if in pain
List non-opiod pain medications
Ibuprofen, acetaminophen, ketorolac, acetylsalicylic acid
List opiod pain medications
Mild/moderate: codeine, oxycodone (oxycodone + acetaminophen = percocet)
Strong: Morphine, hydromorphone (Dilaudid),
Post op Pt. develops temp 101, incision red with foul smelling drainage, what is the post op complication?
Infection
Post-Operation Hemorrhage symptoms include:
Tachycardia
Dependent drainage
Hypotension
Thrombophlebitis, signs and symptoms & treatment
S/S:
Red leg, hot to touch
Edema
Aching
Cramping
Treatment: Immobilize limb, may have heparin
Pulmonary Embolism, signs and symptoms
Sudden onset of dyspnea
Shortness of breath
Cyanosis
Hypotension
Tachycardia
Lower Oxygen Saturation
What are physiological nonverbal indicators of pain?
Tachypnea (High respirations)
Tachycardia
Dilated pupils
Rapid Speech
What are psychological indicators of pain?
Anxiety
Depression
Anger
Fear
Exhaustion
Hopelessness
Irritability
What must be assessed prior to starting a diet for a Post-Op?
( 7 Assessments)
- PCP Orders
- Level of consciousness | Patient is awake, alert
- Patient can swallow
- Is there a gag reflex?
- Functioning GI tract | Patient has bowel sounds
- Does pt have nausea?
- Is pt vomiting
Possible causes of fistula include:
Infection
Pressure
Inflammation
Debris
What is minimum urine output that reflects proper kidney perfusion and fluid balance?
30 mL/hr
A nurse is caring for a client who had an abdominal hysterectomy. Which interventionbestprevents postoperative thrombophlebitis?
Leg exercises 10 times per hour when awake
A client requests pain medication for severe pain. Which should the nurse dofirstwhen responding to this client’s request?
Assess the various aspects of the client’s pain
- 3 Classifications of pain are: origin, cause and duration
Give some evidence of recovery from anesthesia in the PACU
Patient can maintain airway independently
Patient’s vital signs are stable
Patient can move all extremities
