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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

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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”
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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

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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

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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
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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
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7
Q

Who is the first to change the dressing PostOp?

A

The surgeon

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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

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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
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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
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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

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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

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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

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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

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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 -

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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 (14 decks)

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