PACU Complications Flashcards
1
Q
Dyspnea Tachypnea Decreased breath sounds Tachycardia Increased restlessness
A
Atelectasis
2
Q
Increased RR Shallow respirations Fever/chills Wet breath sounds Productive cough Dyspnea Hypoxia Tachycardia Leukocytosis Chest pain
A
Pneumonia
3
Q
Dyspnea Chest pain Cough Cyanosis Increased RR Tachycardia Anxiety
A
Pulmonary Embolus
4
Q
Respiratory Assessments
A
- RR
- Resp. rhythm and depth
- Breath sounds
- O2 saturation level
- Skin color
- Mental status
- Pain
- Airway status
5
Q
Respiratory Interventions
A
- Incentive spirometer
- Cough/deep breathing
- Oral care
- Understanding
- Getting out of bed > 3 times a day
- Head of bed elevation
- Medication for pain control
- Administer oxygen
- Encourage hydration
6
Q
Frank bleeding Anxiety Apprehension Restlessness Decreased BP Clammy skin Mottled extremities Weak pulse Increased RR Decreased urine output Thirst
A
Hemorrhage
7
Q
Pain & cramping in calf/thigh
Redness/swelling of area
Increase temp
Increase diameter extremity
A
Thrombophlebitis
8
Q
Hypotension Tachycardia Diaphoresis Pallor Change in LOC SOB
A
Shock
9
Q
Cardiovascular Assessment
A
- HR and rhythm
- BP
- RR
- Temperature
- Skin color/appearance
- Mental status
- Drain/wound output
- Urine output
10
Q
Cardiovascular Interventions
A
- Utilize warming techniques
- Keep accurate I&O
- Maintain fluid balance
- Apply and maintain compression stockings/devices
- Measure calves daily
- Give anti-coagulatns if prescribed
- Teach/encourage bed mobility
- Assist with ambulation
- Notify physician of abnormal assessment
- Medicate for pain control
11
Q
Dry mucous membranes Thirst Decreased urine output Fatigue HA Decreased BP Increased HR
A
Dehydration
12
Q
Muscle cramps Muscle weakness EKG changes Nausea Constipation Changes in LOC
A
Electrolyte imbalance
13
Q
Fluid & Electrolyte Assessment
A
- Monitor I&O
- Skin turgor/mucous membranes
- IV site, fluids, rate
- Monitor weight
14
Q
Fluid & Electrolyte Interventions
A
- Adminiter IV fluids
- Maintain IV
- Advance diet as ordered/tolerated
- Provide oral care
- Encourage fluid intake
15
Q
Would redness Purulent drainage Fever Tachycardia Leukocytosis
A
Infection of wound
16
Q
Incision seperation
A
Wound dehiscence
17
Q
Bowel profusion through incision
Pain
A
Wound evisceration
18
Q
Wound Assessment
A
- Dressing
- Drains
- Signs of hemorrhage and shock
- Temperature
19
Q
Wound Intervention
A
- Use aseptic technique for wound care
- Administer antibiotics as ordered
- Encourage splining during cough/deep breathing exercises
- Encourage fluid intake and protein intake
- Manage blood sugar levels
20
Q
Inability to void within 8 hrs
Frequent, small amounts of urine
Palpable bladder
Suprapubic pain
A
Urinary retention
21
Q
Decreased bowel sounds No flatus or stool N, V Abdominal distention Abdominal tenderness
A
Paralytic Ileus
22
Q
Nutrition & Elimination Assessment
A
- I&O
- Gag reflex
- Bowel sounds
- Flatus
- N,V
- Possible diet advancement
- Bladder distention
23
Q
Nutrition & Elimination Interventions
A
- Provide oral care
- Encourage fluid and fiber intake
- Assist in voiding position
- Provide privacy
- Bladder scan if necessary
- Utilize GI medications as ordered
- Advance diet as ordered/tolerated
- Encourage/assist with ambulation
24
Q
Possible Post-Operative Nursing Dx
A
- Acute pain
- Impainred skin integrity
- Deficient fluid volume
- Urinary retention
- Ineffective airway clearance
- Risk for infection
- Hypothermia
- Nausea
25
Post-Op Priorities
- Airway: protect and clear
- Breathing: RR & oxygen stats
- Circulation: BP & HR
- Wound
- I&O: IV fluids, drains
- Comfort
- Safety
- Family
