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NURS 362 this shit confuse me > Nursing Management of a Patient with Post-Op Complications > Flashcards

Nursing Management of a Patient with Post-Op Complications Flashcards

1
Q

What are the potential Post-Op complications the nurse must be aware of and monitor for?

A
  • Respiratory complications like atelectasis, pneumonia, pulmonary embolism, and aspiration
  • Cardiovascular complications like shock and thrombophlebitis
  • Functional decline weakness, and fatigue
  • Acute urinary retention or UTI
  • Neurologic effects delirium and stroke
  • GI effects like constipation, paralytic ileus and Bowel obstruction
  • Wound complications like infection, dehiscence, evisceration, delayed healing, hemorrhage, and hematoma
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2
Q

What does the stress response of a post-op patient depend on?

A
  • Pain
  • Fear before and after surgery
  • Anesthesia type and amount
  • Degree of tissue trauma
  • Generally lasts 3-5 days
  • Will see third spacing related to the degree of trauma
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3
Q

What are the 3 phases of post-op recovery?

A

-Phase 1 in PACU
-Phase 2:
outpatient recovery continues in Ambulatory Surgery or out-patient unit
-inpatient recovery is on post-op surgical unit in hospital
Phase 3 :discharge

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4
Q

What is the goal of the PACU and when can they move on to next phase of recovery?

A

-goal is to provide care until patient recovered from effects of anesthesia

Patient can move on when

  • Oriented
  • Stable vital signs
  • Shows no evidence of hemorrhage or other complications
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5
Q

What are the responsibilities of a PACU nurse?

A
  • Review pertinent and baseline information upon admission to unit
  • Assess airway, respirations, cardiovascular function, surgical site, function of CNS, IVs, all tubes & equipment
  • Reassess VS, patient status every 15 minutes or more frequently if needed (or per facility protocol)
  • Transfer report to another unit or discharge to home
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6
Q

Focused Nursing Assessment for patient in PACU

A
  • Airway
  • Breathing
  • Vital Signs
  • Mental Status
  • Surgical Incision Site
  • IV fluids
  • Tubes and Drains
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7
Q

What is PACU Nurse first priority and how is it done?

A

-Maintain a Patent Airway to
allow for ventilation, and oxygenation

Nurse must..
-Watch for stridor, wheezing, sounds that may indicate partial obstruction (laryngospasm)
-Provide supplemental O2 prn
-Assess breathing by placing hand near face to feel movement of air
-Keep HOB 15-30 degrees unless contraindicated
-May require suctioning
If N/V, turn head to side

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8
Q

What is PACU nurse’s second priority and how does nurse do this?

A

-Maintain Cardiovascular stability

Nurse must..

  • Monitor all indicators of cardiovascular status
  • Assess all IV lines
  • Monitor for hypotension, hypertension, shock, hemorrhage and dysrhythmias
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9
Q

What indicators of Hypovolemic shock must the nurse be aware of?

A
  • Pallor
  • Cool, moist skin
  • Rapid respirations
  • Cyanosis
  • Rapid, weak, thready pulse
  • Decreasing pulse pressure
  • Low blood pressure
  • Concentrated urine
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10
Q

What should the nurse do to prevent and releive post-op pain and anxiety?

A
  • Assess patient comfort, presence of pain or N/V
  • Intervene at first indication of nausea
  • Control environment with quiet, low lights,
  • decrease stimulation
  • positioning
  • Administer analgesics as indicated if ordered (often short-acting opioids through IV)
  • Administer anti-emetics if ordered
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11
Q

What should the nurse consider about an elderly Post-Op patient?

A

-Decreased physiologic reserve
-Monitor carefully, and frequently
-Increased confusion
-Dosage
-Hydration
-Increased likeliness of post-op confusion, delirium
-Hypoxia, hypertension, hypoglycemia
-Reorient as needed
Pain

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12
Q

Guidelines for Discharge from PACU?

A
  • Modified Aldrete Score
  • Muscle activity
  • Respiration
  • Circulation (BP)
  • Consciousness level
  • O2 saturation
  • Scored q15min while in PACU;
  • must have score of 7-8 to be discharged
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13
Q

How is Modified Aldrete score calculated?

A 
Muscle Activity: 
2=moves all extremities
1=moves 2 extremities
0=unable to move extremities
\+
Respiration:
2=Breaths deeply and coughs freely
1=dyspneic, shallow or limited breathing
0=Apneic(no breathing)
\+
Circulation:
2=BP=20mm higher than pre-anesthetic level
1=BP 20-50mm higher than pre-anesthetic level
0=BP is 50+mm higher than pre-anesthetic level 
\+
Consciousness:
2=Fully awake
1=Aroused on calling
0=Does not respond
\+
Oxygen Saturation:
2=SpO2>92% on room air
1=supplemental O2 required to maintain 92% SpO2
0=Supplemental mO2 is not maintain SpO2 at 92%
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14
Q

When moving patient from phase 1 to phase 2 recovery the nurse should?

A
  • Give report to nurse on receiving unit including..
  • Procedure
  • Anesthesia used
  • Blood loss, drainage, dressings and IVs
  • patient orientation, vital signs, and Pain control
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15
Q

What is included in a nurse’s respiratory assessment of a patient with post-op complications and how often should it be done?

A
  • Assess Airway upon arrival to unit and every 30 minutes after that for 2 hours, then every 4 hours, then every 24 hours, then every shift
  • look for artificial airway,
  • check pulse oximetry and rate rhythm and quality of breaths
  • Auscultate breath sounds for adequacy, symmetry and any adventitious sounds
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16
Q

What should the nurse do if Assessments raise suspicions of respiratory complications Post-Op

A
  • Chest X-Ray compare post-op to pre-op

- Arterial Blood Gases

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17
Q

What potential respiratory complications must the nurse be aware of in the post-op patient?

A

Atelectasis, Pneumonia,

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18
Q

How should nurse assess post-op patient for atelectasis and what nursing intervention should be implemented if Atelectasis suspected?

A
  • usually occurs 24-48 hours post-op
  • Assess for dyspnea, crackles, fever, productive cough and chest pain
  • Nurse should reposition patient every 1-2 hours,
  • encourage coughing and deep breathing
  • use of inspiratory spirometer
  • Early ambulation, out of bed often
  • Increase fluid intake
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19
Q

Post-op Pneumonia

A
  • usually occurs 3 days post-op
  • Nurse must assess for cause/type
  • Hypostatic pneumonia
  • Infectious
  • Aspiration
  • Immobility
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20
Q

How should nurse assess post-op patient for Pulmonary Embolus and what nursing intervention should be implemented if PE is suspected?

A

Assess for

  • Sudden dyspnea
  • Anxiety
  • Sudden sharp chest pain or upper abdominal pain
  • Cyanosis
  • Tachycardia
  • Weak and rapid pulse
  • Drop of blood pressure

Nurse should

  • Notify physician
  • Monitor vitals,
  • Administer Oxygen,
  • Assess IV status, or Foley catheter status
  • Tests may be ordered: ABG, CXR, CT scan, lung scan
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21
Q

What risks for post-op respiratory complications should the nurse be aware of?

A
  • Obesity
  • Smokers
  • Pre-existing respiratory disease
  • Elderly
  • High location of incision
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22
Q

What potential causes of post-op respiratory complications should nurse be aware of?

A
  • Immobility
  • Pain and fear
  • Infective organisms
  • Narcotic analgesics and anesthesia can lead to:
  • Decreased pulmonary function
  • Decreased ciliary function
  • Decreased mucus clearing
  • Aspiration of vomitus
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23
Q

What are respiratory nursing interventions?

A
  • Prevention of complications
  • Early ambulation
  • Position changes
  • C + DB 10xhour;
  • Inspiratory Spirometer
  • Fluids
  • Avoid abdominal distention
  • If Bronchitis/pneumonia provide patient with cool mist, steam, expectorants, antibiotics
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24
Q

Practice Question:
A 60 year old patient is admitted to PACU after cataract surgery. Which of the following post-op complications could have an adverse effect on recovery?

A

a. Pain
b. Vomiting
c. Disorientation
d. Temporary decrease in oxygen saturation

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25
Q

Practice Question:

When is coughing contraindicated in a post-op patient and why?

A
  • In patients with cranial surgeries like subdural hematoma evacuation, trans-sphenoidal hypophysectomy and tonsillectomies.
  • In patients with increased ICP because coughing increased Intracranial pressure.
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26
Q

How does nurse asses cardiovascular system status?

A
  • vital signs
  • cardiac monitoring
  • Peripheral vascular assessment
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27
Q

How should nurse assess cardiovascular system using Vital signs?

A
  • Q 15 minutes until stable (4 checks) (in PACU)
  • then q ½ hour ( for 2 hours) (on unit)
  • then Q 4hours for 24 hours, then Q8
  • Look for upward and downward trends
  • Report changes of 25 %
28
Q

What may significant decreases or increases in vital signs away from baseline indicate?

A

Decreased vital signs

  • myocardial depression,
  • fluid volume deficit,
  • shock,
  • hemorrhage,
  • med effects,
  • hypothermia

-Increased pulse can indicate pain, shock, hemorrhage

29
Q

Peripheral Vascular Assessment

A
  • Be aware of position in surgery
  • Peripheral pulse assessment important
  • Cap refill
  • Absence of edema
  • Tingling
30
Q

What are 3 main post-op cardiovascular complications?

A
  • Thrombophlebitis
  • Cardiovascular shock
  • Hypertension
31
Q

What is cardiovascular shock, what are the different types and how can the nurse assess for it?

A 
-Insufficient blood circulation to vital organs
Types: 
-hypovolemic,
-sepsis, 
-anaphylaxis, 
-cariogenic, 
-transfusion reaction,
-neurogenic, 
-Pulmonary Embolus

Nurse should Assess for

  • cool, pale moist skin
  • rapid, weak, thready pulse;
  • increased respirations
  • decreased BP
  • dec LOC
32
Q

What is a major cardiovascular risk factor of prolonged post-op immobility and how can it be prevented?

A
  • Thrombophlebitis

- Can be prevented through use of Sequential Compression Devices(SCD)

33
Q

Practice Question:
A patient is getting up for the first walk post-op. To decrease the potential for orthostatic hypotension, the nurse should plan to have the patient:

A

a. Sit in a chair for 10 minutes prior to ambulating
b. Encourage the patient to drink plenty of fluids to increase circulating blood volume
c. Stand upright 2-3 minutes prior to ambulating
d. Sit upright on the side of the bed for 2-3 minutes prior to ambulating

34
Q

How does nurse perform neurological assessment of post-op patient?

A

Assess General cerebral functioning by

  • LOC: eye opening, ability to respond, orientation
  • Compare to baseline
  • Elderly considerations

Motor/Sensory Assessment

  • Especially important after spinal or epidural anesthesia
  • Movement of extremities
  • Compare to baseline info
35
Q

Intake and Output

A

-Vital to establish replacement needs
-I=O generally if healthy
-Adult:
I=2400cc/day
O=1400cc(urine)+500-1000cc(insensible loss)
-Child I/O
125-150cc/kg/day in first year
1250-1500cc/day

36
Q

What are causes of abnormal fluid losses associated with surgery should the nurse be aware of?

A
  • NPO status
  • Vomiting
  • Drainage from tubes and drains
  • NG suctioning
  • Fever
  • Hyperventilation with pain and anxiety
  • Diaphoresis
37
Q

Is oliguria 1-2 days post-op followed by polyuria on day three common and what causes it?

A

Oliguria: Decreased urine r/t sodium and water retention approximately 750cc is normal
(min 30cc.hour= 720 per day)

Polyuria: Increased urine due to third day diuresis.
Large
Amount: inc by 100 percent.(1500-3000cc is normal)

38
Q

What should nurse assess if oliguria is suspected

A

Check for distended bladder because narcotics decrease urge which may lead to urinary retention

39
Q

A patient has experience weight loss post-op what does the nurse explain to the patient as potential causes?

A
  • Decreased intake associated with NPO status with only IV to replace
  • Dehydration with polyuria
  • Increased metabolism (due to healing, increase temp)
  • Protein and fat catabolism: starvation; may lose ½ pound per week
40
Q

Which patients should nurse be especially careful in administering replacement fluids,

A
  • Adult patients with renal, cardiac or pulmonary problems
  • Very young and very old patients
  • Infants/children: there is small margin of error because small changes in fluid volume has greater effects.
41
Q

What findings in the nurse’s assessment of a post-op patient would indicate fluid overload and what complications can this cause?

A
  • Moist Crackles
  • Cough
  • Tachypnea
  • Tachycardia
  • Increased blood pressure
42
Q

What are the causes of post-op urinary retention and how can the nurse assess for it in the patient?

A

Causes can be

  • anesthesia(bladder atony),
  • narcotics,
  • operative trauma,
  • age,
  • disease (BPH),
  • lack of privacy,
  • positioning,
  • bedpan use,
  • pain

Nurse should assess:

  • no void 6-8 hours post-op
  • Feeling of fullness,
  • Distension
  • Small, frequent voids

Remember: output approx. 1550 cc first 48 then 2000-3000cc’s per day

43
Q

What nursing interventions should be used if urine retention is suspected?

A

Stimulate patient by warming pan,

  • run water
  • Help to assume a normal position as possible.
  • Provide Privacy
  • Bladder scan
  • Catheterize as last resort
44
Q

What are potential causes of post-op UTIs

A

Urine stasis with immobility, atony, catheterizations, poor hygiene

45
Q

What assessment findings would indicate to nurse the presence of a UTI?

A
  • Fever,
  • dysuria,
  • frequency,
  • small amounts of output
46
Q

What Nursing Interventions should be used if UTI is suspected?

A
  • Prevention
  • Monitor temp
  • Increase fluids to 2000-3000 cc/day, I+O
  • Keep urine acid
  • Cath
  • Administer Meds
47
Q

What potential causes of Paralytic Ileus should nurse be aware of?

A
  • Anesthesia
  • Excessive handling of bowel during surgery
  • Decreased Potassium
  • Distention with air swallowing,
  • GI secretions,
  • large amount fluid trapped
  • Infection
48
Q

What Assessment findings would indicate paralytic Ileus and what interventions should be implemented if suspected

A

Assess:

  • Absence of bowel sounds for 3-4 days post-op or may develop after liquid diet
  • Nausea/vomiting post-op
  • No flatus or bowel sounds
  • Abdominal discomfort or distention

Interventions:

  • NPO, OOB walking
  • NG LOW intermittent suction always unless specific order.
  • Rectal tube
  • Decreased air swallowing
  • IV fluids
  • K replacement
  • Meds: Reglan (metoclopramide) H2 blockers, proton pump inhibitors
49
Q

What are the 3 phases of wound healing?

A
  1. Inflammation phase:
    - surgery to 4-6 days
    - wound weak,
    - prone to hemorrhage, -sutures hold the wound together,
    - normal to be red, swollen 1-2 days after, but after 3rd day worry about infection
  2. Proliferation phase:
    - after 4-6 days to 2 weeks
    - highly vascular connective tissue,
    - granulation tissue,
    - wound stronger
  3. Maturation phase:
    - 2-3 weeks until up to 1 year
    - increased strength and healing.
    - Still no heavy lifting!
50
Q

What are the 3 types of healing and and 1 example of each?

A
  1. Primary intention:
    -wounds edges closely approximated,
    -minimal trauma and contamination,
    -heals without complications.
    (knee incision post-op)
  2. Secondary intention:
    - wound edges not approximated.
    - Seen with infected wounds, or those with excessive trauma or tissue loss.
    - Granulation tissue leaves a larger scar. Example = a pressure injury
  3. Tertiary:
    - occurs with deep wounds that have not been sutured early or break down and re-sutured later;
    - may decide to delay suturing if infected,
    - 2 opposing granulation surfaces brought together. (abdominal surgical dehiscence)
51
Q

What are potential causes of wound infection the nurse should be aware of?

A
  • Contamination
  • Obesity
  • Diabetes
  • Lengthy surgery causes Increased stress, and decreased resistance
  • Hx of steroids, radiation, anti-neoplastic meds which may dec WBC count
  • Age
  • Debility
  • Malnutrition
52
Q

Assessment for wound infection

A
  • Infection usually occurs 3 days post-op
  • Check for approximation of suture line
  • Assess for
  • fever/chills
  • Bleeding(odor, drainage)
  • pain/redness/edematous skin at incision site,
  • suture tension.

-Observe for sudden, profuse discharge of serosanguinous material = DEHISCENCE or EVISCERATION (usually 6-8 days)

53
Q

What is dehiscence and evisceration and what predisposing factors should the nurse be aware of?

A

-Dehiscence is partial or complete separation of wound tissues
Usually 6-8 days after surgery

-Evisceration is partial or complete separation fo wound tissue and viscera protrudes through the wound
Usually 6-8 days after surgery

Predisposing factors:

  • excessive coughing
  • straining,
  • infection
  • urgent surgeries
  • poor nutrition
54
Q

What is the emergency treatment for Dehiscence?

A
  • Put patient in bed
  • Avoid coughing and straining
  • Elevate head of bed to decrease strain on incision
  • Clean incision and apply saline-moist dressing
  • Contact provider
55
Q

What is the emergency treatment for Evisceration?

A
  • Put patient in bed
  • Avoid coughing and straining
  • Elevate head of bed to decrease strain on incision
  • Clean incision and apply saline-moist dressing
  • cover viscera with saline-soaked sterile towel or dressings
  • Call MD STAT,
  • likely transfer back to OR
  • IV antibiotics
56
Q

What nursing interventions can be used to promote wound healing?

A
  • Prevent infection by washing hands, use clean/sterile technique
  • Monitor temp
  • Assess incisions/wounds every shift
  • Clean wounds properly
  • Assess Dressings
  • Assess Drains
  • Assess retention sutures
  • Assess for factors that may affect wound healing
57
Q

Nursing management of dressings

A
  • Need order to change post-op dressing
  • If wet and no order, reinforce dressing and notify provider
  • If purulent drainage, clean wound then request a culture and sensitivity

-In RN scope of practice, may apply a saline (or wound wash) wet-to-dry dressing without provider order, or follow hospital protocol order or provider order

58
Q

Nursing management of drains

A

Drains prevent fluid accumulation, lower chance of drainage infecting incision

  • MUST know if drain present
  • Monitor COCA (color, odor, consistency, amount)
  • Consider how many days post-op for COCA and what is considered normal progression
  • Monitor increases and decreases in drainage
  • MUST clean around wounds daily and replace dry drain gauze (or other ordered product)
  • MUST assess skin around the drain every shift
59
Q

Wound irrigation and cleaning

A
  • Flush out infected wounds
  • Routine wound care always requires a vigorous cleaning
  • Use spray wound cleansers, saline, hospital product of choice
  • Medicate for pain prior to wound care

-Purpose: to remove infected exudate, promote healthy tissue growth, prep wound for product use

60
Q

What factors affecting wound healing should the nurse be aware of?

A

-adequate circulation needed to deliver nutrients and oxygen to tissues.

Delayed wound healing in:

  • vascular disease
  • obesity
  • DM
  • CV disease
  • edema
  • nicotine
  • poor nutrition
  • infection
61
Q

What major nutritional factors are needed for wound healing and what are some complications if inadequate?

A

Major Nutritional Factors Needed

  • Protein: tissue repair, restore blood volume and lost plasma proteins from exudates or bleeding
  • Calories
  • Nutritional deficit causes -weight loss,
  • delayed healing,
  • edema r/t dec albumin,
  • high risk of infection r/t dec antibody formation
62
Q

What major nutrients are needed for wound healing and what role do they play?

A
  • Water: maintains homeostasis, replaces losses through vomiting, hemorrhage
  • Vitamin C is needed for capillary formation, tissue synthesis, wound healing through collagen formation and antibody formation
  • Thiamine, Niacin, Riboflavin, Folic acid and B12 are needed for red blood cell maturation, (antibiotics may impede)
  • Viamint K needed for Clotting
  • Iron to replace iron if blood loss

-Look at ETOH history

63
Q

What are post-op psychological concerns

A
  • Surgical diagnosis and prognosis
  • Support systems
  • Body image disturbance
  • Ineffective Coping
  • Hopelessness,
  • Powerlessness
  • Spiritual Distress
  • Grieving process
64
Q

What is included in discharge referrals and planning?

A
  • Home Care
  • Meals on Wheels
  • Special Equipment
  • Transportation Assistance
  • Support Groups
65
Q

What should be included in nurses education of post-op patient being discharged?

A
  • Type of Diet
  • Activity Level
  • Bathing
  • Complications such as temp, drainage and pain
  • Report complications
  • Medication teaching and prescriptions
  • Follow up appointments
  • Pain management

NURS 362 this shit confuse me (8 decks)

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