Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NUR 118 Lecture > NUR 118 - Lecture 6 - PeriOp Nursing (Pain) P. 2 > Flashcards

NUR 118 - Lecture 6 - PeriOp Nursing (Pain) P. 2 Flashcards

1
Q

What must be assessed before starting diet?

A

-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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is the progression of diet?

A
  • NPO Post Operatively, then:
    Clear liquid
    Full liquid
    To prescribed diet
    “clear liquids, progress as tolerated”
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are the use of drains?
What are the three drains?

A

Allows fluids to exit tissue, prevent excess pressure building up
Penrose drain, Jackson Pratt drain, Hemovac

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Describe PenRose Drain and nursing responsibilities

A

Flat flexible LATEX (allergies) tube
Only keep in for a few days
Measure exposed parts to track assessment to assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Describe the Jackson Pratt drain and nursing responsibilities

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Nursing responsibilities for Hemovac drain

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Who is the first to change the dressing PostOp?

A

The surgeon

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Difference between Dehiscence and Evisceration

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are Nursing Interventions for Dehiscence?

A
  • Maintain bedrest with HOB @ 20 degrees & knees flexed
  • Apply binder to prevent evisceration
  • Notify provider of occurrence
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are the Nursing Interventions for Evisceration?

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

PostOp Complications: Hemorrhage
Signs/Symptoms, interventions for prevention and treatment

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Post Op Complications: Infection

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Post Op Complications: Thrombophlebitis

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

PostOp Complications: Pulmonary Embolism

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

PostOp Complications: Respiratory - Pneumonia

A

Inflammation of alveoli due to infection with bacteria or viruses; alveoli filling with solid material instead of air
Signs/Symptoms -

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

How should we take the patient’s claim to pain?

A

Pain is whatever the patient says it is whenever he says he has it

17
Q

What are three classifications of pain?

A

Origin, cause, duration

18
Q

What are the types of pain by Origin?

A

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)

19
Q

Types of Pain Classified by Cause

A

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

20
Q

Types of Pain Classified by Duration

A

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

​

21
Q

List non-pharmacologic interventions for pain

A

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

22
Q

PQRST for pain

A

Provoking Factors
Quality
Region & Radiation
Severity
Timing

23
Q

What are the 4 pain Assessment scales?
When to use them

A

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

24
Q

What is an important obstacle towards surgical recovery?

A

Pt will not be able to participate in surgical recovery if in pain

25
Q

List non-opiod pain medications

A

Ibuprofen, acetaminophen, ketorolac, acetylsalicylic acid

26
Q

List opiod pain medications

A

Mild/moderate: codeine, oxycodone (oxycodone + acetaminophen = percocet)

Strong: Morphine, hydromorphone (Dilaudid),

27
Q

Post op Pt. develops temp 101, incision red with foul smelling drainage, what is the post op complication?

A

Infection

28
Q

Post-Operation Hemorrhage symptoms include:

A

Tachycardia
Dependent drainage
Hypotension

29
Q

Thrombophlebitis, signs and symptoms & treatment

A

S/S:
Red leg, hot to touch
Edema
Aching
Cramping

Treatment: Immobilize limb, may have heparin

30
Q

Pulmonary Embolism, signs and symptoms

A

Sudden onset of dyspnea
Shortness of breath
Cyanosis
Hypotension
Tachycardia
Lower Oxygen Saturation

31
Q

What are physiological nonverbal indicators of pain?

A

Tachypnea (High respirations)
Tachycardia
Dilated pupils
Rapid Speech

32
Q

What are psychological indicators of pain?

A

Anxiety
Depression
Anger
Fear
Exhaustion
Hopelessness
Irritability

33
Q

What must be assessed prior to starting a diet for a Post-Op?
( 7 Assessments)

A
  • 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
34
Q

Possible causes of fistula include:

A

Infection
Pressure
Inflammation
Debris

35
Q

What is minimum urine output that reflects proper kidney perfusion and fluid balance?

A

30 mL/hr

36
Q

A nurse is caring for a client who had an abdominal hysterectomy. Which interventionbestprevents postoperative thrombophlebitis?

A

Leg exercises 10 times per hour when awake

37
Q

A client requests pain medication for severe pain. Which should the nurse dofirstwhen responding to this client’s request?

A

Assess the various aspects of the client’s pain
- 3 Classifications of pain are: origin, cause and duration

38
Q

Give some evidence of recovery from anesthesia in the PACU

A

Patient can maintain airway independently

Patient’s vital signs are stable

Patient can move all extremities

NUR 118 Lecture (10 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions