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Peri-op > PACU nurse role and pt assessment > Flashcards

PACU nurse role and pt assessment Flashcards

1
Q

PACU handover (NOPAIMMPSCCPC)

A
  • name and age
  • operative procedure
  • pre-op assessment
  • allergies
  • intraoperative events
  • monitoring and lines
  • medications administered
  • postoperative orders
  • surgeons and anaesthesia name
  • check pt name against medical record and bracelet
  • care and placement of surgical drains
  • problems with skin pressure area
    -care of belongings
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2
Q

What is shallow respiration a sign of

A

sign of continuing depression from anaesthesia, or perioperative meds.

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3
Q

Cause of quiet breathing

A

Normal

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4
Q

cause of no sound

A

Complete airway obstruction

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5
Q

cause of snoring

A

Tongue falling back in throat.

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6
Q

cause of Bubbling and gurgling

A

Fluid, such as blood or vomit in throat

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7
Q

cause of Crowing/stridor

A

Laryngospasm

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8
Q

cause of Wheeze/whistling

A

Foreign body present, bronchospasm

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9
Q

cause of Stridor

A

Vocal cord oedema after extubating, foreign body.

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10
Q

Any fluid/foreign material in the mouth or pharynx should be removed by suction as it may:

A
  • Obstruct the airway
  • Irritate the larynx and cause laryngeal spasm
  • Be inhaled into the lungs of laryngeal reflexes have not yet returned
  • Provoke violent coughing spasms
  • Avoid mucosal damage the wall suction unit should be set between 100-120mmHg.
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11
Q

Indications of suction

A
  • Any sound is heard during respiration
  • Obvious secretions and or the patient begins to vomit
  • Pt is failing to saturate well
  • Any sign of airway obstruction.
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12
Q

Managing airway patency - oropharyngeal airway

A

Most common is the guedel
- inserted to prevent the tongue falling back and obstructing breathing.
- check position to ensure the lips don’t come between teeth and airway as bleeding and swelling may occur.

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13
Q

Managing airway patency - nasopharyngeal airway

A
  • required if airway can’t be maintained by guedel
  • jaws are clammed tightly
  • jaws are wired together
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14
Q

Laryngeal oedema - airway emergency

A

Feature of acute inflammation
- presents shortly after extubation
- common feature is post-extubation stridor
- results from damage to the mucosa of the larynx

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15
Q

Laryngospasm - airway emergency

A

A sudden and violent contraction of the vocal cords that may result in complete or partial closure of the trachea.
- unable to speak or breathe

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16
Q

malignant hypertension / hypertensive emergency

A

Severely elevated BP.
- blurry vision
- change in mental status
- chest pain
- cough
- headache
- nausea or vomiting
- Numbness in the arms, legs, face

17
Q

Postoperative hypertension nursing intervention

A
  • Notify anaesthesia if pt has systolic BP >180mmHg, diastolic >105mmHg in two or more readings.
  • Identify the cause of HTN and manage
  • Give 02 and monitor vital signs
  • persistently high, attach ECG and monitor for rhythm changes
  • monitor for signs of malignant hypertension
18
Q

Postoperative hypotension - nursing management

A
  • Identify cause
  • Hypovolemia - fluid bolus may be indicated
  • elevate pt leg, don’t tilt the bed
  • increase 02 sat
  • agitation, chest pain, discomfort - ECG to check for rhythm changes
  • If pt has good perfusion, and their BP is within 15% of baseline reading, there is no need for intervention however strict monitoring is required.
19
Q

types of fluid solutions

A
  • Crystalloids
  • Colloids
  • Blood/blood products
20
Q

Classifying fluids

A
  • isotonic
  • hypertonic
  • hypotonic
21
Q

goal of Fluid replacement therapy

A

maintain adequate intravascular volume to ensure cellular oxygen deliver and cardiac output

22
Q

Absolute hypovolemia

A

Reduction in total circulating blood volume,.
Results from haemorrhage, gastrointestinal loss, drainage or diuresis.

23
Q

Relative hypovolemia

A

Fluid volume moves out of the vascular space into the extravascular space
- This is called third spacing.

24
Q

Hypovolemia signs

A
  • Postural hypotension - pt feels faint when sitting up if BP falls >20mmHg
  • Severe hypotension can cause nausea
  • Vasoconstriction - cap refill > 2 seconds, hands begin to cool.
  • Tachycardia, weak thready pulse
  • Decrease UO, <0.5ml/kg/hr
  • Sweating
  • Poor skin turgor
  • Agitation and anxiety.
25
Q

Hypervolemia

A

Too much fluid in the blood/body.

26
Q

Hypervolemia causes

A

Body’s normal stress response to surgery.
- ADH release leads to increased blood volume (hormone responsible for BP homeostasis)
- ACTH stimulates the adrenal cortex to secrete aldosterone, leading to significant sodium and fluid retention.
- Fluid shifts to the intravascular space from administration of hypertonic solutions

27
Q

Hypervolemia signs

A
  • Ascites
  • Oedema - hands, feet, ankles
  • Strong and rapid pulse
  • Change in respiratory pattern
  • Crackles on auscultation
  • Dyspnoea and orthopnoea
  • High BP
  • Jugular vein distension
  • Increased CVP
28
Q

Delayed awakening causes

A
  • Drug effects
  • Metabolic disorders
  • Neurological disorders
29
Q

Emergency delirium - risk factors

A
  • pre-existing dementia or confusion
  • Advancing age (>65)
  • Alcohol use
  • Hearing or vision impairment
  • Prescence of urinary catheter or ETT
  • Surgical blood loss with post-op Hct <30%
  • Intraoperative complications, e.g., hypoxia
  • Use of psychoactive drugs, i.e., Ketamine
  • Hypoglycaemia
  • Pain
30
Q

two components of heat input

A
  1. internal heat production
  2. heat transfer from the environment
    *disruption to these two principles will produce either hypothermia or hyperthermia.
31
Q

Hypothermia - causes

A

Temp drops below 35.
- intrinsic factors
- surgical factors
- environmental factors
- general anaesthesia

32
Q

Hyperthermia causes in PACU

A
  • bacterial or viral infection
  • over-heating with artificial warmers
  • Some meds - psychotropic drugs, SSRI’s, MAOI’s and tricyclic antidepressants
  • Malignant hyperthermia
33
Q

Malignant hyperthermia definition

A

type of severe reaction that occurs in response to particular medications used during general anesthesia,

34
Q

Malignant hyperthermia signs

A

tachycardia, tachypnea, hypoxemia, hypercarbia, metabolic and respiratory acidosis, hyperkalemia, cardiac dysrhythmias, hypotension, skeletal muscle rigidity, and hyperthermia.

35
Q

Discharge from PACU

A
  • Minimum observation time of 30 minutes
  • Pt can adequately maintain their own airway
  • Pt is hemodynamically stable
    02 sats not <93%
  • Sedation score not > 2
  • Vital signs within 20% of baseline
  • Pain scores not >3
  • Normothermic
36
Q

Risk factors for respiratory complications (general)

A
  • supine position
  • obese
  • COPD
  • Hx of smoking
  • airway abnormalities
  • older age
37
Q

Risk factors for respiratory complications (anaesthetic related)

A
  • unconscious
  • intubated pt
  • difficult intubation
  • use of opioids
  • GA
  • use of neuromuscular blocking agents
  • over sedation
38
Q

Risk factors for respiratory complications (surgical related)

A
  • abdominal surgery
  • neck surgery
  • emergency surgery
  • long duration > 3 hrs

Peri-op (10 decks)

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