PACU Complications Flashcards

1
Q
Dyspnea
Tachypnea
Decreased breath sounds
Tachycardia
Increased restlessness
A

Atelectasis

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2
Q
Increased RR
Shallow respirations
Fever/chills
Wet breath sounds
Productive cough
Dyspnea
Hypoxia
Tachycardia
Leukocytosis
Chest pain
A

Pneumonia

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3
Q
Dyspnea
Chest pain
Cough
Cyanosis
Increased RR
Tachycardia
Anxiety
A

Pulmonary Embolus

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4
Q

Respiratory Assessments

A
  • RR
  • Resp. rhythm and depth
  • Breath sounds
  • O2 saturation level
  • Skin color
  • Mental status
  • Pain
  • Airway status
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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
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6
Q
Frank bleeding
Anxiety
Apprehension
Restlessness 
Decreased BP
Clammy skin
Mottled extremities
Weak pulse
Increased RR
Decreased urine output
Thirst
A

Hemorrhage

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7
Q

Pain & cramping in calf/thigh
Redness/swelling of area
Increase temp
Increase diameter extremity

A

Thrombophlebitis

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8
Q
Hypotension
Tachycardia
Diaphoresis
Pallor
Change in LOC
SOB
A

Shock

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9
Q

Cardiovascular Assessment

A
  • HR and rhythm
  • BP
  • RR
  • Temperature
  • Skin color/appearance
  • Mental status
  • Drain/wound output
  • Urine output
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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
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11
Q
Dry mucous membranes
Thirst
Decreased urine output
Fatigue 
HA
Decreased BP
Increased HR
A

Dehydration

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12
Q
Muscle cramps
Muscle weakness
EKG changes
Nausea
Constipation
Changes in LOC
A

Electrolyte imbalance

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13
Q

Fluid & Electrolyte Assessment

A
  • Monitor I&O
  • Skin turgor/mucous membranes
  • IV site, fluids, rate
  • Monitor weight
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14
Q

Fluid & Electrolyte Interventions

A
  • Adminiter IV fluids
  • Maintain IV
  • Advance diet as ordered/tolerated
  • Provide oral care
  • Encourage fluid intake
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15
Q
Would redness
Purulent drainage
Fever
Tachycardia
Leukocytosis
A

Infection of wound

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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
Q

Post-Op Priorities

A
  • Airway: protect and clear
  • Breathing: RR & oxygen stats
  • Circulation: BP & HR
  • Wound
  • I&O: IV fluids, drains
  • Comfort
  • Safety
  • Family